Prescription Benefits

Prescription plan coverage is available to all individuals and their dependents who are eligible for health benefits with the State. The State’s prescription plan is administered by Express Scripts (1-877-213-3867). The prescription plan covers the cost of approved prescription drugs, subject to nominal copayments. These copayments are determined by whether the drug is on the Express Scripts formulary and whether the drug is a brand-name or generic.

Express Scripts

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Participating Pharmacies

If you use a pharmacy that participates in the Express Scripts network, you only need to pay the necessary co-payment at the time of service. More than 900 pharmacies in the state of Maryland participate in the Express Scripts network. Express Scripts also has a nationwide network of participating pharmacies. If you are traveling out-of-state or just want to know if a particular pharmacy participates in the Express Scripts network call 1-877-213-3867.

Non-Participating Pharmacy

If you visit a pharmacy that is not a member of the Express Scripts network, you must pay the pharmacist the entire cost of your prescription drug and submit a paper claim form to Express Scripts for reimbursement. You will be reimbursed the amount that the State would have paid a Express Scripts pharmacy minus a $12.50 copayment. This amount may be less than your out-of-pocket cost. You have one year from the date you have a prescription filled to submit a paper claim to Express Scripts.

If you must obtain a prescription without a Express Scripts Enrollment Card, you will need to submit a Express Scripts claim form for reimbursement. Please send your completed claim form and receipt to:

Employee Benefits Division
301 W. Preston St., Room 510 Baltimore, MD 21201
Attn: Express Scripts Coordinator

All claims must be submitted within one year of the date of service.

How to Receive Prescription Plan Benefits

Please take your Express Scripts card with you when you get prescriptions filled. If you are enrolling in the prescription plan for the first time, Express Scripts will issue you a maximum of two cards per family. An additional card may be ordered for students residing out of state, by calling Express Scripts. Any stolen cards must be reported to Express Scripts immediately. All cards are issued with the name of the employee or retiree embossed on the card. Dependent names are not listed on the card.

If you choose a formulary drug, you will pay a $25.00 co-payment when you purchase the drug. If your physician has prescribed a drug that is not on Express Scripts formulary, the copayment will be $40.00. If you purchase a brand-name drug when a generic drug is available, you must pay the difference between the brand-name and generic drug, in addition to the standard co-payment amount of $25.00 or $40.00. Preferred generic drugs have $10.00 co-payments.

Terms You Should Know

Formulary: A formulary is a preferred list of drugs. Express Scripts has a panel of physicians and pharmacists that meets regularly to identify and review prescription drugs that provide the highest therapeutic and economic value. By choosing drugs on this list, your physician helps keep the cost of prescription drugs affordable. Formulary drugs are subject to change at any time. Your physician may contact Express Scripts to obtain information on formulary drugs

Brand-name drug: A brand-name drug is any approved drug a particular pharmaceutical company has the exclusive right to produce and sell. Over time, companies can lose the patents on particular drugs, opening up the market to generic equivalents. Generic drug equivalents may become available at any time.

Generic drug: A generic drug is made with the same active ingredient as found in the brand-name product. All generics must meet the same manufacturing testing standards as the brand-name drug. If a generic drug is available, the State plan only covers up to the cost of the generic.

NOTE: The State prescription plan only covers up to the cost of a generic drug, when the generic is available. If you purchase a brand-name drug when a generic drug is available, even if it is prescribed by your physician, you must pay the difference in price between the brand-name and the generic, as well as the standard co-payment amount. The plan does not pass judgment on a physician’s determination as to the appropriate medication for treatment, but the plan does have limitations as to the types and amounts of reimbursement available.

 

Last updated: September 12, 2017