Faculty & Staff Prescription Drug Benefits

Faculty & Staff Prescription Drug Benefits

Faculty and Staff pay the prescription drug amounts as shown in the charts below.

CareFirst BlueCross BlueShield, EHP Classic or BlueChoice HMO

Our prescription drug coverage is offered through Express Scripts. This chart provides your out-of-pocket copays for prescription drugs with CareFirst BlueCross BlueShield, EHP Classic or BlueChoice HMO.

  Retail
(up to a 30-day supply)
Mail Order
(up to a 90-day supply)
 
Generic $10 copay $25 copay
Formulary Brand* If no generic is available, 20% coinsurance ($30 minimum; $45 maximum) If no generic is available, 20% coinsurance ($75 minimum; $112.50 maximum)
Non-Formulary Brand* If no generic or formulary brand is available, 25% coinsurance ($60 minimum; $100 maximum) If no generic is available, 25% coinsurance ($150 minimum; $250 maximum)
Annual Out-of-Pocket Maximum $2,000 per individual
$6,000 for three or more family members
$2,000 per individual
$6,000 for three or more family members

*A formulary brand drug is one that is on the approved drug list, or formulary. A non-formulary brand drug is one that is not on that list.

The university wants to help you use your prescription drug benefits wisely. The following programs will help you get the best medication at the right price:

  • Mandatory generics - member pays the difference (for existing and newly filled prescriptions). Generic drugs are lower-cost medications that are just as effective as brand-name drugs. You may pay more if you purchase a brand medicine when a generic-equivalent drug is available. You will pay the generic copay plus the difference in cost between the brand and generic drug.
  • Prior authorization (applies to new prescriptions in certain drug categories after 1/1/2018; current are grandfathered while in continuous use). Some medications will require prior authorization, or review and approval, before the plan will cover the cost. This is to ensure that the medication you receive is safe and effective for your situation. Prior authorization may be required for drugs that:
    • Have potentially dangerous side effects
    • Are harmful when combined with other drugs
    • Are often misused
    • Are prescribed when less expensive drugs are as effective
    • Are specialty medications that are meant to treat very specific diseases and require appropriate clinical markers (biological characteristics that help assess whether a drug will be effective in a specific patient)
  • Step Therapy (applies to certain new prescriptions after 1/1/2018; current are grandfathered while in continuous use). Step Therapy requires you to try lower-cost (often generic) medications first, before "stepping up" to medications that cost more. If your medication requires Step Therapy, you will be obligated to try a step-one medication before "stepping up" to a step-two (or step-three) medication. Step-one alternative medications are proven to be safe, effective, and affordable; and, can provide the same health benefits as more expensive medications at a lower cost to you.
  • Quantity limitations (for existing and newly filled prescriptions). To reduce waste and ensure that the most cost-effective product strength is prescribed, all medications will be subject to quantity limitations (as determined by the FDA). If your treatment exceeds the quantity limitation of your drug, your prescription will require further authorization.

If your medication needs approval, either you or your pharmacist will need to let your doctor know. Your doctor might switch your therapy to another drug that does not require prior authorization, step therapy, or quantity limitations by calling Express Scripts at 1-888-406-1213 to start the approval process.

Kaiser Permanente

If you choose medical coverage through Kaiser Permanente, your prescriptions will be processed by Kaiser Permanente. This chart provides your out-of-pocket copays for prescription drugs with Kaiser Permanente.

  Kaiser Pharmacy
(up to a 30-day supply)
Community Pharmacy
(up to a 30-day supply)
Mail Order
(up to a 90-day supply)
 
Generic $15 copay $20 copay $30 copay
Formulary Brand* $25 copay $45 copay $50 copay
Non-Formulary Brand* $40 copay $60 copay $80 copay
Annual Out-of-Pocket Maximum Integrated with medical Integrated with medical Integrated with medical

*A formulary brand drug is one that is on the approved drug list, or formulary. A non-formulary brand drug is one that is not on that list.