Your prescription drug FAQs answered
6-minute read
In January, Express Scripts Medicare® (PDP) and Express Scripts became the administrators for the HealthSelectSM Medicare Rx and HealthSelectSM Prescription Drug Program, respectively.
Overall, the new contract offers lower drug prices for the majority of our members. However, a new administrator could mean some people have to find a new pharmacy, pay more or less for a medication, or see other changes in how they get their prescription drugs. We’ve gathered some of the most frequently asked questions (FAQs) from members 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 Day 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. Express Script’s 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 drug list 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 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, HealthSelect Secondary, HealthSelect Out-of-State and HealthSelect Medicare Advantage, there’s a $50 per person prescription drug deductible. 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. For those in Medicare, when you’ve paid a certain amount for prescription drugs, you enter the Medicare Part D “donut hole” and start paying either the plan copay or 25% of the negotiated cost of the drug. Because out-of-pocket costs reset on Jan. 1, you would leave the donut hole Jan. 1 and won’t re-enter it until you have incurred enough out-of-pocket expenses.
You used a pharmacy that isn’t in the Express Scripts network. In all plans, 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 learn more about the prior authorization process by logging in to your Express Scripts account online, clicking the “Prescriptions” drop-down menu and clicking “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 Express Scripts website. You also can 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 one card per household. Dependents can use those even if they have the primary member’s name on them for non-Medicare plans. 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 HealthSelect Medicare Rx, and you’re in the HealthSelect 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 ask for additional cards by calling Express Scripts.
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
Non-Medicare members
Grace period ends for drugs not in formulary on March 31
On Jan. 1, Express Scripts allowed non-Medicare members access to drugs not in the Express Scripts formulary until March 31. If you are taking a drug not in the Express Scripts formulary, this grace period will end. Beginning April 1, you will have to get an alternative medication, receive a prior authorization to stay on your current medication, or pay out of pocket for the drug.
All members
Prior authorizations and step therapy 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.
Have more questions?
If you have specific questions about your coverage, please contact Express Scripts depending on your prescription drug plan.
- HealthSelect Prescription Drug Program (non-Medicare)
- Call Express Scripts toll-free at (800) 935-7189 (TTY: 711) 24 hours a day, seven days a week or visit HealthSelectRx.com.
- HealthSelect Medicare Rx (enrolled in Medicare)
- Call Express Scripts Medicare (PDP) toll-free at (866) 264-4676 (TTY: 711) 24 hours a day seven days a week or visit HSMedicareRx.com.
Join a webinar
Join Express Scripts and ERS representatives for an overview of the HealthSelect Prescription Drug Plan or the HealthSelect Medicare Rx Plan. Learn more about your coverage, where to find resources online and how to best use your prescription drug benefits. You'll have the opportunity to ask questions through each webinar’s questions inbox.- April 9 at 10 a.m CT. - HealthSelect Prescription Drug Program (non-Medicare) Q&A Session with Express Scripts
- April 11 at 1 p.m. CT - HealthSelect Prescription Drug Program (non-Medicare) Q&A Session with Express Scripts
- April 16 at 10 a.m. CT - HealthSelect Medicare Rx Q&A Session with Express Scripts
- April 18 at 1 p.m. CT - HealthSelect Medicare Rx Q&A Session with Express Scripts