Health Care Benefits Brochure - Pension Fund

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Health InsuranceNote about out-of-network providers:Remember, you will reach your out-of-pocket maximumquicker when you use providers that are out of theBCBS network. In addition, separate deductibles andout-of-pocket limits exist for out-of-network medicalservices. The medical summary of benefits enclosedshows a comparison between benefits when you usein-network providers and benefits when you use out-ofnetworkproviders.Also, keep in mind that your health plan pays theallowed price for services and supplies. In-networkproviders agree to accept the allowed price as paymentin full. When you use out-of-network providers, youmust pay the difference between the allowed price andthe provider’s charge. Benefits for most services requirethat you pay a deductible each year for in-networkprovider services and out-of-network providers’services. After you have met your deductible, you sharethe cost of your care through coinsurance. Deductibleand out-of-pocket amounts do not cross apply. Again,your coinsurance percentage amount for out-ofnetworkprovidersis higher than the one forin-network providers.You need only pay thedeductible andcoinsurance until youmeet your out-of-pocketmaximum for the year.Tier 1 (Generic): $10Tier 2 (Brand Formulary): 20%($25 minimum/$75 maximum)Tier 3 (Brand Non-Formulary): 50%($40 minimum/$120 maximum)When you go to in-network pharmacies, you will beresponsible for paying the copay or coinsurance – nothingmore. The pharmacy will bill Express Scripts for theleftover amount. As you can see, you will pay the lowestcopay if you use a generic drug. Make sure to ask yourpharmacist if a generic alternative is available for thebrand-name drug you are prescribed.You must use pharmacies that are in Express Scripts’network to receive the benefit levels above. Over 90% ofpharmacies nationwide currently belong to this network.Should you use an out-of-network pharmacy, you will beresponsible for the co-pay listed above plus 20% of theremaining cost of the drug.The plan provides for three refills of medication at a retailpharmacy. After this, the plan will require you to pay anadditional cost; unless you have this medication filledusing Express Scripts by Mail.Brand Formulary-Name DrugsPrescription Drug Program: Express ScriptsThe CCHCBT, through its partnership with ExpressScripts, a pharmaceutical benefit manager, has a tieredprescription drug program. That means that you pay thelowest co-payments when you use tier 1 (generic) drugs.Below is the co-payment structure at retail pharmaciesfor a 30-day supply:Annual Deductible: $50 individual; $100 FamilyFollowing are some definitions of brand formularynamedrugs:Brand-name drug – a prescription drug that is marketedunder a proprietary, trademark-protected name.Tier 2 prescription drug – a “preferred” brand-name drug.A list of these preferred drugs is provided by Express Scripts,your pharmacy vendor. Many factors are taken into accountwhen deriving the list, such as the utilization of the drugs,their cost and the therapeutic class.6
Wouldn’t you ratherpay $4 for yourprescription?What is important to know is that Tier 2 prescription drugsare less expensive than Tier 3 prescription drugs. Tier 3prescription drugs are non-preferred and are at the highestcoinsurance level.Formulary Drug List – This list, which is updatedquarterly to ensure the newer, more effective drugs areon it, is available to you by registering at www.expressscripts.com.Once there, you can download the formularylisting or search for a medication by name. Drugsautomatically come off the list when generic alternativesbecome available.You may want to print off the most updated formulary listand take it with you to your next doctor’s appointment.If your next doctor has the list, he or she can be sure toprescribe a preferred drug.Mandated GenericsIf you purchase non-preferred drugs, including nonsedatingantihistamines (Allegra®, Clarinex®, Zyrtec®, etc.),or if you purchase a brand medication when a generic isavailable, you will pay your copay plus the difference incost between the brand and generic.Express Scripts By Mail PharmaciesMore than six million members enjoy the convenienceand savings of having their long-term medications(maintenance medications, those taken for three monthsor more) delivered to their home or office. Express Scriptsby Mail advantages include:• Getting up to a 90-day supply (compared with atypical 30-day supply at retail) of each coveredmedication for just one mail order payment.- Tier 1 (Generic): $20- Tier 2 (Brand Formulary): 20%($60 minimum/$180 maximum)- Tier 3 (Brand Non-Formulary): 50%($100 minimum/$300 maximum)Did you know thatWal-Mart offers morethan 300 different drugs at only $4 perprescription fill or refill (up to a 30-day supply or60 pill maximum)? The program is available at allWal-Mart, Sam’s Club and Neighborhood Marketpharmacies. A similar program is also offeredthrough Target stores.• Ordering refills 24 hours a day online, by mail orby phone. To order online, register at www.expressscripts.com.Refills are usually delivered within threeto five days after Express Scripts receives your order.You can also have your doctor fax your prescriptions.Ask your doctor to call 888.327.9791.• Choosing a convenient payment option. Express Scriptsoffers two safe, automatic options for prescription orders.You can use e-check to have payments automaticallydeducted from your checking account, or you can useAutoCharge to have payments charged automaticallyto your credit card. For more information, visitwww.express-scripts.com or call member services at800.418.9925.Specialty MedicationsSpecialty medications are drugs that are used to treatcomplex conditions, such as cancer, growth hormonedeficiency, hemophilia and multiple sclerosis. ExpressScripts’ specialty pharmacy, Accredo Health Group,Inc., is composed of therapy-specific teams that providean enhanced level of personalized service to patientswith special therapy needs. By ordering your specialtymedications through Accredo, you can receive:• Personalized counseling from our dedicated team ofregistered nurses and pharmacists.• Expedited, scheduled delivery of your medications atno charge.• Complimentary supplies, such as needles and syringes.• Refill reminder calls.• Safety checks to help prevent potential druginteractions.7
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Health Care Benefits Brochure - Pension Fund

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