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

2018 Open Enrollment

November 1-14, 2017

Prescription Drug Coverage

All of the university’s medical plans include prescription drug benefits through Express Scripts, with no need to enroll in a separate prescription drug plan.

  • Prescription medications are available via home delivery mail-order service and nationwide retail pharmacy locations. You choose which option is most convenient for you and your family.
  • 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. To locate a network pharmacy, use the Locate a Retail Pharmacy tool offered by Express Scripts.
  • With the Express Scripts mobile app, you can manage your prescriptions on-the-go. Features include refilling and tracking the status of home delivery prescriptions, viewing lower-cost medications available and setting reminders. You can also compare your out-of-pocket costs based on the days’ supply of medication, as well as where you are purchasing it. Go to express-scripts.com and select “Register Now” or download the Express Scripts mobile app for free from your mobile device’s app store and select “Register Now” in the app.
  • You will be able to purchase a 90-day prescription at certain preferred retail pharmacies such as Kroger, Walmart and Meijer for medications you take on an ongoing basis. Like Home Delivery, your cost for obtaining a 90-day prescription at certain preferred pharmacies will be less than obtaining three 30-day prescriptions. To purchase your maintenance medication at a retail pharmacy, you must present a 90-day prescription, and you must use a pharmacy in Express Scripts’ Retail90 network. You also can continue to use home delivery for your 90-day prescriptions, if desired.
  • Specialty medications are pharmaceutical products that treat serious, chronic conditions and typically have a very high cost. In 2018, the maximum amount that a plan member will pay per prescription for each specialty medication purchased will be $50 for generics and $100 for formulary brand-name drugs. There continues to be no maximum out-of-pocket for non-formulary brand-name specialty medications.
  • Previously, Walgreens pharmacies were excluded from the Ohio State network except for the Walgreens in the Wexner Medical Center and OSU East. Beginning January 1, 2018, the Walgreens pharmacies in the Wexner Medical Center and OSU East will also be excluded from the Ohio State pharmacy network. Specialty medications and other prescription drugs are available at The Ohio State University Outpatient Pharmacy.
  • To comply with the Affordable Care Act, statins used for the primary prevention of cardiovascular disease will be covered at 100%. When purchased at a preferred pharmacy, low- to moderate-dose statins will be covered at no cost to plan members for adults 40-75 years old with no history of cardiovascular disease. These medications include:
    • Atorvastatin
    • Fluvastatin IR and XL
    • Lovastatin
    • Pravastatin
    • Simvastatin
    • Rosuvastatin

    Use the pharmacy locator to find a preferred pharmacy.

Effective Jan. 1 – Dec. 31, 2018

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Prescription Drug Plan
PRIME CARE ADVANTAGE
PRIME CARE CHOICE
OUT-OF-AREA PLAN
PRIME CARE CONNECT
Annual Out-of-Pocket Maximum1 $2,500 per person, $5,000 per family $2,000 per person, $4,000 per family
Deductible2 $50 per person, $100 per family No deductible
Preferred Pharmacy Non-Preferred Pharmacy Home Delivery or Retail90 Pharmacy3 Preferred Pharmacy Non-Preferred Pharmacy Home Delivery or Retail90 Pharmacy3
Supply Limitations 30-day supply 30-day supply 90-day supply 30-day supply 30-day supply 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

Value Based Drug Plan4, 5, 6
PRIME CARE ADVANTAGE
PRIME CARE CHOICE
OUT-OF-AREA PLAN
PRIME CARE CONNECT
Preferred Pharmacy Home Delivery or Retail90 Pharmacy3 Preferred Home Delivery or Retail90 Pharmacy3
Supply Limitations 30-day supply 90-day supply 30-day supply 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

Specialty Medication Plan
Feature Retail Delivery OSUWMC Pharmacy and Accredo
Supply Limitations 30-day supply
Generic Drug Not Available 20% coinsurance, up to $50
Formulary Brand Name Drug 20% coinsurance, up to $100
Non-Formulary Brand Name Drug 50% coinsurance, no maximum

Infertility Medication Plan7, 8, 9, 10
Feature Retail Delivery Home Delivery
Lifetime Maximum Benefit $15,000
Supply Limitations 30-day supply
Generic Drug 20% coinsurance, up to $50 20% coinsurance, up to $50
Formulary Brand Name Drug 30% coinsurance, no maximum 30% coinsurance, no maximum
Non-Formulary Brand Name Drug 50% coinsurance, no maximum 50% coinsurance, no maximum

1 The Prescription Drug Program annual out-of-pocket maximum is based on plan enrollment and is separate from the medical plan annual out-of-pocket
maximum.
2 The deductible applies to brand name medications only.
3 Retail90 is Express Scripts’ program which allows individuals to fill their prescriptions for up to a 90-day supply via select retail pharmacies.
4 The Value-Based Drug Plan 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 yp4h.osu.edu to learn more about the Care Coordination Program.
5 Non-Formulary Brand Name Drugs are not eligible for the Value-Based Drug Plan.
6 The Value-Based Drug Plan is not available at Non-Preferred Pharmacies.
7 The infertility treatment medical benefit includes the cost of prescription medications and requires prior authorization from OSU Health Plan.
8 The Prescription Drug Program annual out-of-pocket maximum does not apply to infertility medications.
9 Infertility treatment has a separate lifetime maximum benefit.
10 The infertility drug coinsurance does not have a maximum coinsurance per prescription for formulary and non-formulary brand name medications.

NOTE: The Prescription Drug Plan, Value-Based Drug Plan and Specialty Medication Plan designs have a combined deductible and annual out-of-pocket maximum.

Certain prescription drugs require prior authorization. Once approved, the authorization is valid for up to one year. If a prescription drug requiring prior authorization is not approved for coverage under the plan, you will be responsible for paying the full cost of the medication. (see List of Medications Requiring Prior Authorization)

For greater details about the Prescription Drug Program, refer to the Medical Plans Specific Plan Details document. If the information in this summary differs from the Specific Plan Details document, the Specific Plan Details document will govern.

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Preventive Drug List
Drug Category Eligibility Criteria
Aspirin for cardiovascular disease Men age 45 to 79 years AND
Women age 55 to 79 years
Aspirin for preeclampsia Women of child-bearing years, who are at increased risk of preeclampsia after 12 weeks gestation
Oral fluoride supplementation Children from birth through 5 years old
Iron supplementation in children Children from birth to 12 months of age
Folic acid supplementation All women planning or capable of pregnancy
Breast cancer prevention Subject to prior authorization:

  • Tamoxifen (generic)
  • Raloxifene (generic)
  • Soltamox (Tamoxifen liquid) (brand)
Vitamin D Men and women 65 years or older
Vaccines See OSU Health Plan Forms & Downloads
Bowel Preparations Certain bowel preparation agents for screening colonoscopy for men and women ages 50 to 75 years
Statin drugs for the primary prevention of cardiovascular disease Low- to moderate-dose statins for men and women age 40-75 years. These medications include:

  • Atorvastatin
  • Fluvastatin IR and XL
  • Lovastatin
  • Pravastatin
  • Simvastatin
  • Rosuvastatin

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Women’s Health/Contraceptive Coverage
Drug/Device Category Eligibility Criteria
At least one form of women’s contraception in each of the 18 “methods” of contraception outlined in the FDA birth control guide. See OSU Health Plan Forms & Downloads Women only. No age restriction.

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Tobacco Cessation Coverage
Drug Category Eligibility Criteria
Prescription and Over-the-Counter products with a physician prescription. Men and women age 18 and older.

 

Open Enrollment Information