Prescription Drugs from a Participating Retail Network Pharmacy
Benefits are provided for outpatient Prescription Drug Products dispensed by a participating Retail Network Pharmacy. The following supply limits apply:
• As written by the provider, up to a consecutive 31-day supply of a Prescription Drug Product, unless adjusted based on the drug manufacturer's packaging size or based on supply limits.
• A one-cycle supply of an oral contraceptive. You may obtain up to three cycles at one time if you pay the applicable Co-insurance for each cycle supplied based on the type of pharmacy used (standard retail pharmacy or 90-day network pharmacy).
Note: For covered Prescription Drug Products dispensed from an Out-of-Network Pharmacy, the same rules apply for reimbursement.
If you request a Brand-name Prescription Drug Product in place of the chemically equivalent Prescription Drug Product (Generic equivalent), you will pay the applicable Generic Co-insurance in addition to the difference between the Brand and Generic Drug costs.
Note: Pharmacy benefits apply only if your prescription is for a Covered Health Service, and not for experimental, investigational or unproven services. Otherwise, you are responsible for paying 100% of the cost.
Your Co-insurance is determined by the tier to which the Express Scripts Prescription Drug List (PDL) Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the PDL are assigned to Tier 1, Tier 2 or Tier 3. Please consult your PDL, view at Express-Scripts.com/GeorgiaSHBP, or call the Express Scripts Member Services number on your Member ID card to determine tier status.
Note: Prescription Co-insurance does not apply to the Deductible or the Member’s Out-of-Pocket Maximum. Co-insurance payments will not be overridden or changed on an individual basis.
Coverage for up to a 31-day supply for a participating Retail Network Pharmacy:
Tier 1: 15% Min $20, Max $50 Tier 2: 25% Min $50, Max $80 Tier 3: 25% Min $80, Max $125
Coverage for up to 31-day supply from a Retail Non-Network Pharmacy
In most cases, you will pay more if you obtain Prescription Drug Products from an Out-of-Network Pharmacy. If the out of network pharmacy you use bills more than the plan would reimburse for that same drug to a network pharmacy under their contracted rates then you must pay the difference in cost plus your Co-insurance as outlined below.
The following supply limits apply:
• As written by the provider, up to a consecutive 31-day supply of a Prescription Drug Product, unless adjusted based on the drug manufacturer's packaging size or based on supply limits.
• A one-cycle supply of an oral contraceptive. You may obtain up to three cycles at one time if you pay a Co-insurance for each cycle supplied.
Coverage for up to a 31-day supply for a non-participating Retail Pharmacy:
Tier 1: 15% Min $20, Max $50 Tier 2: 25% Min $50, Max $80 Tier 3: 25% Min $80, Max $125
Specialty Prescription Drug Products from Accredo, an Express Scripts Specialty Pharmacy For Benefits provided for outpatient Specialty Prescription Drug Products dispensed by Accredo, an Express Scripts Specialty Pharmacy, the following apply:
• As written by a Physician up to a 31 day supply; or
• Up to a 31-day supply, unless adjusted based on the drug manufacturer's packaging size or based on supply limits
• When a Specialty Prescription Drug Product is packaged or designed to deliver in a manner that provides more than a 31-day supply, the Co-insurance that applies will reflect the number of days dispensed.
You must use Accredo to receive coverage for Specialty Prescription Drug Products. Initially, you may obtain one fill of your Specialty Prescription Drug Product from a participating Retail Network Pharmacy. Thereafter, you will be required to use Accredo to continue coverage for your Specialty Prescription Drug Product. If you do not use Accredo, the Specialty Prescription Drug Product is not eligible for coverage and you will be required to pay the Full Retail Cost for that prescription at the retail pharmacy.
Specialty Coverage for up to a 31-day supply from Accredo:
Tier 1: 15% Min $20, Max $50 Tier 2: 25% Min $50, Max $80 Tier 3: 25% Min $80, Max $125
Prescription Drug Products from Express Scripts Home Delivery
The following supply limits apply for Benefits for outpatient Prescription Drug Products dispensed by the Express Scripts Pharmacy Home Delivery Service:
• As written by the provider, up to a consecutive 90-day supply of a Prescription Drug Product, unless adjusted based on the drug manufacturer's packaging size or based on supply limits.
• Your doctor must write your prescription for a 90-day or 3-month supply with refills when appropriate (not a 1-month supply with three refills).
Note: You will be charged a 90-day Home Delivery Service Co-insurance regardless of the days’
supply actually dispensed.
To fill the prescription, you may:
• Mail your prescription(s) along with the required form in the envelope provided with your Welcome Package.
• Ask your Doctor to call 888-327-9791 for instructions on how to fax the prescription. Your Doctor must include your Member ID number.
• Order through the Express Scripts website after registering at Express-Scripts.com/GeorgiaSHBP.
Note: If you submit a prescription for a 1-month supply to the Express Scripts Pharmacy Home Delivery service, it will be filled but you will be charged the 90-day Co-insurance amount, so make sure you submit only maintenance prescriptions that you take on a regular basis for a full 90-day supply from Home Delivery.
Coverage up to a consecutive 90-day supply through Home Delivery:
Tier 1: 2 ½ x the monthly Co-insurance for up to a 90-day supply 15% Min $50, Max $125 Tier 2: 2 ½ x the monthly Co-insurance for up to a 90-day supply 25% Min $125, Max $200 Tier 3: 2 ½ x the monthly Co-insurance for up to a 90-day supply 25% Min $200, Max $313
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Express Scripts offers two ways to obtain up to a 90-day supply of maintenance drugs.
1. Some participating retail pharmacies in our Network allow you to get up to a 90-day supply of maintenance drugs at the home delivery Co-insurance rates. These are called 90-day retail network pharmacies. To determine which participating retail pharmacies pass through the discounted Co-insurance rates for a 90-day supply, visit Express-Scripts.com/GeorgiaSHBP and click “Locate a pharmacy.” Any participating 90-day retail pharmacy will have the following statement after the address: “Dispenses a maintenance supply: YES”. You can also locate participating retail pharmacies on the Express Scripts mobile app or call Express Scripts at the number on the back of your Member ID Card.
2. You can use the Express Scripts Pharmacy Home Delivery Service.