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Prescription drugs

Both the CareFirst and the Kaiser medical plan options provide prescription drug coverage for a wide selection of drugs. 

Your prescription drug coverage is in the form of a three-tier benefit structure based on a formulary (preferred drug list). The amount you pay varies, depending on whether you purchase a generic or brand name drug and whether the drug is included in the plan's formulary.

To save out-of-pocket costs and help control the community's health care costs, discuss with our doctor what medication is most appropriate for you based on your condition and out-of-pocket costs and ask if there is a generic or preferred brand equivalent. The majority of drugs prescribed by your doctor will already be on the formulary.

Cost for prescription drug coverage

The cost for prescription drugs is included in your medical cost for the CareFirst or Kaiser options.

Prescription drug coverage comparison chart
  Express Scripts Kaiser Permanente
  In-network Kaiser Center Pharmacy Outside Pharmacy

*After the first three retail prescription fills for maintenance drugs, CareFirst participants pay an additional $10 for each retail fill. Use CVS Smart90 program or switch to home delivery to avoid the surcharge.

**Excluded drugs do not apply towards out-of-pocket maximums.

Generic drugs, retail
(30-day supply)

$10

$10

$20
Brand name formulary drugs, retail*
(30-day supply)

30% coinsurance to $30 maximum

$20

$40
Brand name non-formulary drugs, retail*
(30-day supply)

50% coinsurance to $50 maximum

$35

$55

Excluded drugs**, retail

100% participant responsibility

Not applicable

Not applicable

Generic drugs, home delivery
(90-day supply)

$25

$20

$20

Brand name formulary drugs, home delivery
(90-day supply)

30% coinsurance to $75 maximum

$40

$40

Brand name non-formulary drugs, home delivery
(90-day supply)

50% coinsurance to $125 maximum

$70

$70

Excluded drugs**

100% participant responsibility

Not applicable

Not applicable

Out-of-pocket maximum**, individual

$3,850

Included with medical

Included with medical

Out-of-pocket maximum**, individual + 1 or family

$7,700

Included with medical

Included with medical

Use the home delivery program for drugs you take on an ongoing basis for conditions such as arthritis, high cholesterol, diabetes, and high blood pressure. This program is a great option to help you save on copayments. You can order a 60- to 90-day supply of maintenance medication by mail. Most medications are delivered right to your doorstep. Once your order is set up, you can request refills online or by phone.

The step therapy program is designed for patients with certain conditions that require them to take medications regularly. In this program, the medication therapy for a medical condition begins with the most cost-effective medication, and progresses to other more costly therapies should the initial medication not provide adequate therapeutic benefit.

If is is documented in your prescription drug history that you had previously tried a generic medication and it was not effective, you will bet be affected by this program.

In step therapy, medications are grouped into categories.

Step one: first line medications that are mostly generic medications proven safe, effective, and affordable. These medications are to be tried first.

Step two: second line line medications that are mostly higher costing brand name medications.

Certain chronic and non-chronic drug classes are subject to step therapy. For example, step therapy medication classes include cholesterol, acne, antidepressants, acid reflux, and anti-inflammatories. If your physician writes a new prescription for a medication that is part of the step therapy program, and the medication is not already part of your documented prescription drug history, your physician will need to write you prescription for a first line medication.

Always talk to your doctor before discontinuing or changing any medication. 

 

Express Scripts for CareFirst participants

Express Scripts is a third-party prescription drug benefit provider and is not part of CareFirst, so be sure to present your Express Scripts card to have your prescriptions filled at retail pharmacies.

Under the three-tier prescription drug program, there is a prior authorization requirement for some drugs. For these drugs, Express Scripts requires that physicians call Express Scripts for prior authorization before they write prescriptions and/or authorize refills on current prescriptions.

To determine whether your prescription requires a prior authorization, call Express Scripts customer service at 877-486-5984 or go online to www.express-scripts.com. Without prior authorization, you will pay the full price of the prescription rather than the coinsurance amount.

Medications taken regularly (maintenance medications) can be filled through Express Scripts home delivery or at your local CVS pharmacy for a 90-day supply.

You can fill a maintenance medication at a retail pharmacy for a 30-day supply at the retail copy up to three times. After three, additional 30-day refills are subject to an additional $10 charge.

Drug quantity management (DQM) is designed to provide the medication you need for your good health while ensuring that you receive the amount - or quantity - considered safe. This gives you the right amount to take the daily dose considered safe and effective, according to the guidelines from the U.S. Food & Drug Administration.

Drug quantity management helps save money in two different ways. First, if your prescription is available in different strengths, you may be able to take one dose of a higher strength instead of two or more of a lower strength. Second, DQM helps to minimize the amount of extra supplies that you may accumulate over time.

Excluded medications are not covered under the Express Scripts plan. Each of the excluded drugs have 1-5 alternatives covered under the plan that you can discuss with your doctor. If you choose to receive an excluded medication, you will be responsible for the full cost of the prescription. Excluded prescriptions are also not applicable toward the out-of-pocket maximum.

Certain specialty prescriptions will be required to be filled by CuraScript/Accredo. There are some specialty medications that are not subject to this requirement. Contact Express Scripts with any questions at 877-486-5984.

 

Kaiser Permanente

Prescriptions can be filled at a plan pharmacy located within a Kaiser facility or at a participating network or community pharmacy. Members may also choose to fill maintenance and other long-term medications at a Kaiser facility or through the home delivery service offered through www.kaiserpermanente.org.

American University makes every effort to ensure the accuracy of the information that appears on the benefits site. However, if there are discrepancies between the information presented and the legal documents governing a plan or program (the "plan documents"), the plan documents will always govern. American University reserves the right to amend or terminate any benefit plan at its sole discretion at any time, for any reason.

Kaiser Permanente

Customer Service: 301-468-6000
www.kaiserpermanente.org

Terms to know

Generic drugs meet the same standard quality and is an ingredient or therapeutic match to the brand name equivalent. Generic drugs cost less.

Brand name preferred (formulary) drugs have no generic equivalent and are included on the plan's preferred drug list. You will pay more for preferred brand name drugs than for generic drugs.

Brand name non-preferred (non-formulary) drugs are not included on the plan's preferred drug list for which there is an ingredient or therapeutic equivalent in the generic or brand name preferred tiers. These drugs cost the most.