Your prescription drug questions answered
6-minute read
On Jan. 1, 2024, Express Scripts became the administrator for the HealthSelectSM Prescription Drug Program.
Overall, the new contract offers lower drug prices for most of our members. We’ve gathered some of the most frequently asked questions from participants since the transition.
Pharmacies
Q: How do I find an in-network pharmacy?
You can find pharmacies near you with the Express Scripts® mobile app, by calling Express Scripts or via the “Find a Pharmacy” tool on the prescription drug plan’s website (no login needed).
Q: I take a medication that comes from a specialty pharmacy. How does this work?
Many specialty medications are available at Extended Days’ Supply (EDS) retail pharmacies. You can use the “Price a Medication” tool to show the cost of your medication as well as pharmacies nearby that have your medication. The Express Scripts specialty pharmacy is called Accredo®. If you would like more information about Accredo, please contact Express Scripts.
Drug costs
Q: How do I find out if my medication is covered?
You can check a medication’s price using the “Price a Medication” tool, checking the prescription drug list PDF on the plan’s website or by calling Express Scripts.
Q: Why has the cost of my medication changed?
There are four possible reasons the cost of your medication changed after Dec. 31:
Express Scripts has different contracts with drug manufacturers and pharmacies than the previous administrator. Express Scripts negotiates prices with drug manufacturers and dispensing fees with pharmacies. In all plans except Consumer Directed HealthSelectSM, these contracts, along with clinical factors, help determine which of the three 30-day retail copay tiers a drug goes in.
- The tier 1 copay, for generic drugs, is $10.
- The tier 2 copay, for preferred brand drugs, is $35.
- The tier 3 copay, for non-preferred brand drugs, is $60.
Since the transition, some medications might have moved to a higher or lower tier and/or might have different dispensing fees.
In Consumer Directed HealthSelect, you pay the full-negotiated cost of a drug until you meet the combined prescription drug and medical deductible. After the deductible, you pay coinsurance, that is, a percentage of the negotiated cost. So, if Express Scripts is paying a different price and dispensing fee for a drug than the previous administrator paid, you will pay a different price, too.
It’s important to note that the administrator regularly negotiates with drug manufacturers and pharmacies, so your out-of-pocket costs could change even when there’s not a change in administrators.
Each year deductibles start over on Jan. 1. In HealthSelect of Texas®, HealthSelectSM Secondary and HealthSelectSM Out-of-State, there’s a $50 per person prescription drug deductible that the participant must pay before the plan pays anything. In Consumer Directed HealthSelect, there’s a combined prescription and medical deductible. You pay the full-negotiated cost of your drugs until you meet the deductible. After that, you pay a copay or, for Consumer Directed HealthSelect, coinsurance. In all plans, the deductible is based on the calendar year, Jan. 1 – Dec. 31.
You used a pharmacy that isn’t in the Express Scripts network. Costs are higher if you use an out-of-network pharmacy. Find an in-network pharmacy on the plan’s website or Express Scripts app, or by calling the plan.
Drug prices go up and down, just like the price of gas or a carton of eggs. Drug shortages, manufacturing costs and high demand can cause drug costs to spike or drop. You can check a medication's price before filling a prescription by using the "Price a Medication" tool, checking the drug list on your plan's website or by calling Express Scripts.
Q: If I need to get prior authorization for a medication, how do I start the process?
Contact Express Scripts or to learn more about the prior authorization process:
- Log in to your Express Scripts account on the plan website.
- Click the “Prescriptions” drop-down menu.
- Click “Prior authorizations.”
Q: Are COVID-19 at-home tests covered?
No. You are responsible for the full cost of at-home over-the-counter COVID-19 antigen tests and test kits. Last May, the U.S. Department of Health and Human Services ended the COVID-19 national public health emergency, which ended coverage of tests and test kits by the federal government. Insurers are also no longer required to offer coverage at no cost.
ID Cards
Q: I don’t know where my ID card is. What do I do?
You can access a digital copy of your card in the mobile app or by logging in to your account on the plan website. Call Express Scripts member services. If you never got a card from Express Scripts, you should call them as soon as possible.
Q: I’m a dependent on my spouse’s insurance. Why haven’t I received my own card?
Express Scripts welcome packet included two cards per household. Dependents can use those even if they have the primary member’s name on them. If you are in a different plan than your spouse, you’ll get a welcome kit for your plan. (For example: Your Medicare-enrolled spouse is in HealthSelectSM Medicare Rx, and you’re in the HealthSelectSM Prescription Drug Plan because you’re not yet eligible for Medicare.) Make sure you use the correct card for the correct plan when visiting a pharmacy. You can also access a digital copy of your card by logging in to your account online or through the mobile app. Or you can call Express Scripts member services and ask for additional cards.
Weight loss drugs
Q: Are any weight loss drugs covered?
No. ERS’ prescription drug plans currently do not cover drugs prescribed for the treatment of obesity/weight loss. Some medications used for the treatment of type 2 diabetes result in weight loss. These medications, such as Ozempic®, are subject to prior authorization. They are covered only after confirmation of type 2 diabetes diagnosis.
Prescription drug reminders
The grace period ended on March 31 for drugs not in formulary.
When Express Scripts became the administrator on Jan. 1, they allowed a grace period for participants who were then taking drugs that are not in the Express Scripts formulary. The grace period ended March 31. Now, you have to get an alternative medication, receive a prior authorization to stay on your current medication or pay out of pocket for the drug.
Renew prior authorizations or step therapy for some medications.
If you were taking a drug that required prior authorization or step therapy under the previous administrator, is in the Express Scripts formulary and requires prior authorization or step therapy under Express Scripts, you will have to go through a new prior authorization or step therapy once the prior authorization or step therapy expires. You also might pay a different price, depending on what formulary tier the drug is in. Please contact Express Scripts if you have questions.
Questions?
If you have specific questions about your coverage, please Express Scripts toll-free at (800) 935-7189 (TTY: 711) 24 hours a day, seven days a week or visit HealthSelectRx.com.