No. The prescription drug deductible is separate from the medical plan deductible and must be met before your prescription drug copays apply. For example, if you enroll in the Memorial Hermann ACO or KelseyCare HMO option and have a prescription for a preferred brand-name drug with an actual price of $195, you first pay your $75 annual deductible ($195 - $75 = $120) and then your $35 retail copay ($120 - $35 = $85), and then the plan pays the remaining $85. Once you pay the $75 deductible amount, you only pay the appropriate copay for each other prescription for that covered person for the rest of the year.
Open Access Select members pay a $250 deductible for an individual or $500 for a family.
The prescription drug program includes a formulary, or primary, drug list. A formulary is a list of preferred drugs that meet a patient's clinical needs at a lower cost than other drugs. Formulary drugs are FDA-approved and selected for their safety, quality, effectiveness and cost efficiency. The primary drug list is included in your prescription drug benefit kit and available on the ExpressScripts website. This list is subject to change.
You might want to ask your doctor to look at the formulary list. He or she may not be aware of an equivalent drug that’s available on the Express scripts preferred formulary list. If you and your doctor still want the non-formulary drug, it’s covered, but at the higher non-formulary brand-name copay, which is still a significant savings over paying the full retail price.
You pay the non-preferred brand-name copay under your medical coverage option. If you choose a brand-name drug when a generic alternative is available, you pay the brand-name copay plus the difference in cost between the generic and brand-name drug.
To keep your costs down, you should:
Use in-network pharmacies
Ask your doctor to prescribe generic drugs or drugs that are on the preferred drug list
Use the Home Delivery mail service or any Express Scripts Smart90 retail partner for maintenance prescriptions
Use a health care flexible spending account when appropriate
Using the health care flexible spending account (FSA) can save you money. If you’re taking maintenance medications, you can estimate:
That you typically need to see your primary care physician (PCP) or specialist at least once a year
The monthly or annual cost of the drug
This makes it easy to set aside pre-tax dollars in the Health Care FSA to pay yourself back for these costs.
Using generic drugs can save you and the plan money. A generic drug is a copy of an original brand-name drug that many companies now manufacture. Substituting generic for brand-name generally has no side effects. If your doctor prescribes a brand-name drug, ask if there’s a generic alternative because generic drugs are generally less expensive. In addition, if you choose a brand-name drug when a generic alternative is available, you pay the brand-name copay plus the difference in cost between the generic and brand-name drug.
Yes. Copays are waived for generic medications that treat high cholesterol, asthma, hypertension and diabetes, including injectable insulin. Take advantage of the Smart90 network (see next question) to receive a 90-day supply through the Smart90 retail partners, including Kroger, HEB, Costco, Randalls, Sam's and Walmart.
Important: If you use any pharmacy other than Express Scripts to fill your maintenance medications after the first two fills, even for free generic drugs, you only receive a 30-day supply, but are charged the full 90-day mail order copay.
The first two times you purchase a 30-day supply of a prescribed maintenance medication at a participating retail pharmacy, you pay your annual pharmacy deductible, if required, and your normal retail copay.
After that, you can save money by purchasing 90-day supplies of your maintenance medications through the Express Scripts mail service or at a local retail partner. These include Kroger, HEB, Costco, Randalls, Sam’s and Walmart. Ask your physician for a 30- or 60-day prescription for your initial fill(s) and a second prescription for a 90-day supply and refills for up to one year, if appropriate, so you can take advantage of these savings.
Aldine Independent School District uses coverage management programs to help ensure you receive the prescription drugs you need at a reasonable cost. Coverage management programs include prior authorization, step therapy and quantity duration. Each program is administered by Express Scripts to determine whether your use of certain medications meets your Plan’s conditions of coverage. In some cases, a coverage review may be necessary to determine whether a prescription can be covered under your Plan.
If your prescription requires prior authorization, you or your doctor can initiate the prior authorization review by calling Express Scripts at 855-712-1403. Express Scripts will inform you and your doctor in writing of the coverage decision.
For any benefits question or concern, including 24/7 Nurse Line access, one call does it all.
Call us at 866-284-AISD (2473)