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Prescription Drug Benefits Overview


For full details about the prescription drug benefits available from the DGA–Producer Health Plan, refer to the March 2020 Health Plan Summary Plan Description, beginning on page 67.

Prescription Drug Network

Express Scripts is the Health Plan’s prescription benefit manager.

To locate an Express Scripts network pharmacy, go to express-scripts.com or call (800) 987-7828.

Below is a summarized schedule of prescription drug benefits under the Health Plan.

Retail Pharmacy Mail Order/Walgreens Smart90 Program
Deductible There is no deductible associated with the prescription drug benefit.
Allowable Quantity Up to 30-day supply Up to 90-day supply
Generic Drug Co-Payment $10 $25
Brand Name Drug Co-Payment $24 $60
Lifestyle Drug Co-Payment
(i.e. erectile dysfunction drugs, proton pump inhibitors and sleep aides.		 Greater of $40 or 50% of the
cost of the medication		 Greater of $60 or 50% of the
cost of the medication

There are special rules for coverage of proton pump inhibitors and sleep aides. See the “Lifestyle Drugs” section beginning on page 70 of the March 2020 Health Plan Summary Plan Description for more information.

Generic contraceptives are covered at 100% under the Health Plan’s Preventive Care Services benefit.

Drugs that are not listed in the Express Scripts formulary are not covered under the Health Plan. This affects a small number of brand name medications. To find out whether your current prescription is listed in the formulary, log on to your Express Scripts account at express-scripts.com/covered.

If you choose to take a brand name drug when a generic equivalent is available, you will pay the cost difference between the two drugs plus the generic co-pay.

MAINTENANCE MEDICATIONS

If you are taking a maintenance medication (three months or more), you are allowed two 30-day fills at a retail pharmacy. After the first two fills, to avoid paying the entire cost of the medication, you will be required to obtain your medication in 90-day supplies, using one of the following two options:

  1. Express Scripts Home Delivery
    1. Obtain a 90-day prescription for your maintenance medication from your doctor.
    2. Complete the Express Scripts Home Delivery Order Form available here or by visiting www.express-scripts.com.
    3. Attach your 90-day prescription(s) to your completed form (which will include your payment information) and return both documents to Express Scripts at the address provided on your Order Form.
    4. Your medication(s) will be delivered to your home.
  2. Walgreens (may operate as Duane Reade or as Happy Harry’s in certain regions of the country)
    1. Obtain a 90-day prescription for your maintenance medication from your doctor.
    2. Fill your 90-day prescription in person at any participating Walgreens, Duane Reade or Happy Harry’s pharmacy.

    For questions about the program, please call (866) 890-1419 or visit www.express-scripts.com/90day.

For more information on maintenance medications, please refer to pages 67-69 of the March 2020 Health Plan Summary Plan Description.

NON-NETWORK PHARMACIES

You may purchase your medication at a non-network pharmacy, but you will have higher costs and will have to file a claim with Express Scripts for reimbursement.