Open Enrollment – Prescription Drug Benefits - Human Resources at Ohio State

2023 Open Enrollment

November 1-15, 2022

Prescription Drug Benefits

The Ohio State University Faculty and Staff Health Plan includes prescription drug benefits administered by Express Scripts. There is no need to enroll in a separate prescription drug benefit.

Prescription medications are available via home delivery mail-order service and nationwide retail pharmacy locations. You choose the option that is most convenient for you and your family.

You may obtain a 90-day prescription for maintenance medications through Express Scripts Home Delivery or at an eligible retail preferred pharmacy through Retail90.

The Express Advantage Network allows members to take advantage of higher savings at a preferred retail network pharmacy. You may use retail pharmacies that are not preferred pharmacies in the Express Advantage Network, but your out-of-pocket costs will be higher. Pharmacies in the preferred retail network are subject to change. Examples currently include but are not limited to:

  • Costco*
  • Discount Drug Mart*
  • Giant Eagle*
  • Marc’s
  • Meijer*
  • OSU Outpatient Pharmacy*
  • Rite Aid*
  • Walmart*

*Retail90 available

2023 Prescription Drug Benefits

Express Scripts (ESI) does not provide a hard copy ID card. Access to an electronic ID card is available on the ESI mobile app.

To register for an online account, visit express-scripts.com. When you download the Express Scripts mobile app in Apple iTunes or Google Play, you can use the same username and password as your online account. The mobile app allows you to access your ID card, check the status of your prescriptions, order refills and find your nearest preferred pharmacy.

Members have the option to print a card from the website if they prefer.

Effective Jan. 1 – Dec. 31, 2023

2023 Prescription Drug Benefit1 PDF Version
PRIME CARE ADVANTAGE
PRIME CARE CHOICE
OUT-OF-AREA
PRIME CARE CONNECT
Annual Out-of-Pocket Maximum2,3 $2,500 per person, $5,000 per family $2,000 per person, $4,000 per family
Deductible4 $50 per person, $100 per family No deductible
Preferred Pharmacy Non-Preferred Pharmacy Home Delivery or Retail90 Pharmacy5 Preferred Pharmacy Non-Preferred Pharmacy Home Delivery or Retail90 Pharmacy5
Supply Limitations up to 30-day supply up to 30-day supply up to 90-day supply up to 30-day supply up to 30-day supply up to 90-day supply
Generic Drug $10 copay $20 copay $25 copay $8 copay $18 copay $20 copay
Formulary Brand Name Drug 30% coinsurance, up to $100 35% coinsurance, up to $110 30% coinsurance, up to $250 30% coinsurance, up to $40 35% coinsurance, up to $50 30% coinsurance, up to $100
Non-Formulary Brand Name Drug 50% coinsurance, no maximum 55% coinsurance, no maximum 50% coinsurance, no maximum 50% coinsurance, no maximum 55% coinsurance, no maximum 50% coinsurance, no maximum
1 Specific preferred insulin products will be available for a $25 copay per 34-day supply and a $75 copay per 90-day supply through the Express Scripts Patient Assurance Program only at Preferred Pharmacies.
2 The Prescription Drug Benefit annual out-of-pocket maximum is based on benefit enrollment and is separate from the medical benefit annual out-of-pocket maximum.
3 Fertility treatment has a combined medical and pharmacy $15,000 lifetime maximum and is limited to a 30-day supply per fill. Prior Authorization from OSU Health Plan is required.
4 The deductible applies to brand name medications only.
5 Retail90, also known as Smart90, is Express Scripts’ program which allows individuals to fill their prescriptions for up to a 90-day supply via select retail pharmacies.

Individuals are notified by Express Scripts if a change to the formulary means their prescription cost will increase. Notification will be provided in a letter mailed to the home address on record.

The Ohio State University Faculty and Staff Health Plan members who are actively participating in the Care Coordination Program for management of asthma, chronic obstructive pulmonary disease (COPD), diabetes and/or heart disease (coronary artery disease or congestive heart failure) are eligible for the VBD. The VBD copay for certain eligible generic drugs taken for these chronic condition(s) will be waived and the member cost-share for certain eligible formulary brand-name drugs taken for the chronic condition(s) will be reduced by 50%. Only eligible members who choose to actively participate in the Care Coordination Program are eligible for the VBD. Eligible VBD medications obtained at a non-preferred pharmacy will not receive the VBD discount and will be subject to the applicable benefit copay/coinsurance.

Effective Jan. 1 – Dec. 31, 2023

2023 Value Based Drug Benefit1,2,3 PDF Version
PRIME CARE ADVANTAGE
PRIME CARE CHOICE
OUT-OF-AREA
PRIME CARE CONNECT
Preferred Pharmacy Home Delivery or Retail90 Pharmacy4 Preferred Home Delivery or Retail90 Pharmacy4
Supply Limitations up to 30-day supply up to 90-day supply up to 30-day supply up to 90-day supply
Generic Drug $0 $0 $0 $0
Formulary Brand Name Drug 15% coinsurance, up to $50 15% coinsurance, up to $125 15% coinsurance, up to $20 15% coinsurance, up to $50
Non-Formulary Brand Name Drug 50% coinsurance, no maximum 50% coinsurance, no maximum 50% coinsurance, no maximum 50% coinsurance, no maximum
1 The Value-Based Drug Benefit eligibility is based on actively participating in the Care Coordination Program for management of specific chronic conditions (asthma, chronic obstructive pulmonary disease (COPD), diabetes, and heart disease). Visit osuhealthplan.com to learn more about the Care Coordination Program.
2 Non-Formulary Brand Name Drugs are not eligible for the Value-Based Drug Benefit.
3 The Value-Based Drug Benefit is not available at Non-Preferred Pharmacies.
4 Retail90, also known as Smart90, is Express Scripts’ program which allows individuals to fill their prescriptions for up to a 90-day supply via select retail pharmacies.

Specialty medications are frequently high-cost pharmaceutical products that are biotechnological in nature and available only through specialty pharmacies. The Ohio State Wexner Medical Center Outpatient Pharmacy and Accredo specialty pharmacy through Express Scripts are the only pharmacies in the exclusive specialty network. If you do not have your specialty medication filled at one of these two pharmacies, it will not be covered.

Effective Jan. 1 – Dec. 31, 2023

2023 Specialty Medication Benefit1 PDF Version
Feature Retail Delivery OSUWMC Pharmacy and Accredo2
Supply Limitations up to 30-day supply
Generic Drug Not Available 20% coinsurance, up to $50
Formulary Brand Name Drug Not Available 20% coinsurance, up to $100
Non-Formulary Brand Name Drug Not Available 50% coinsurance, no maximum
1 Certain specialty medications are included in the SaveonSP copay assistance program and subject to a different copay structure. While there are copays associated with each product included in the SaveonSP program, the member copay will be $0. If an individual chooses not to enroll in SaveonSP, they will be responsible for the prescription drug copay for qualified medications, and the copay amount will not apply to the Prescription Drug Benefit out-of-pocket maximum.
2 In certain cases, the outpatient pharmacy at Nationwide Children’s Hospital may also fill prescriptions under the Specialty Medication Benefit. Contact OSU Health Plan for details.

For greater details about the Prescription Drug Benefit, refer to the 2023 Faculty and Staff Health Plan Specific Plan Details (SPD) Document. If the information in this summary differs from the Specific Plan Details document, the Specific Plan Details document will govern

Open Enrollment Information