Page 6 - 2022-23 Drug Plastics Benefit Guide

Highmark Medical and Pharmacy Plan Overview

Making the most of your plan
Getting the most out of your plan also depends on how well you understand it. Keep these important tips in mind when
you use your plan.
΅ In-Network Providers: Participating providers agree to ΅ Mandatory Generic Program: If a doctor prescribes a
accept the Highmark Blue Shield allowance as payment brand-name drug, it will be substituted with a generic
in full (often less than their normal charge). drug, if available, unless the doctor specifically requests
΅ Out-of-Network Providers: If you visit a provider that a brand-name drug that is medically necessary. If you
does not participate, you are responsible for paying the elect to receive a brand name drug when a generic
deductible, coinsurance and the difference between equivalent is available, your cost will be the copay for the
what the provider charges and what the Plan pays. brand name drug plus the difference in cost between
Please refer to Highmark Open Enrollment booklet for the brand name drug and the generic drug. Note: If you
Out-of-Network responsibility. purchase a brand name drug and a generic drug is NOT
΅ Inpatient Admission (and certain other services) may available, you will continue to pay only the brand name
require preauthorization or precertification. drug copay.
΅ Preventive Care: In-Network preventive care is covered To find out whether your prescription is a generic,
at 100% (no cost to you). Preventive care is often received
during an annual physical exam and includes routine brand-name formulary or brand-name non-formulary
physical exams, immunizations, mammograms and drug, please check with your local pharmacist or call
other services intended to prevent illness or detect Express Scripts at 800-903-6228 or log onto
problems before you notice any symptoms. See Highmark www.express-scripts.com.
Preventive Schedule for specific services and limitations.
΅ Waiving Medical Coverage: Eligible employees also ΅ Medicare Part D: The prescription drug plan is credible
have the option to waive medical coverage offered coverage. Medicare-eligible participants need not enroll
through Drug Plastics. This opt-out may be a good in a separate Medicare D drug plan.
choice if you have coverage options through another ΅ Preferred Formulary Drugs are brand name drugs
plan, such as a spouse’s plan. If your spouse loses available to you at a reduced cost. FDA-approved
coverage due to a termination of employment or plan medications prescribed by your physician will require
cancellation, you may rejoin the Drug Plastics Benefit specified copays and coinsurance based on whether
Plan by notifying the Human Resource Department they are brand, preferred formulary or generic drugs.
within 30 days of the event. Otherwise, you may rejoin ΅ Smart90 – Maintenance Medications: The Smart90
the plan at the next annual open enrollment period. program requires maintenance medications to be
΅ In-Network Pharmacies: Participating pharmacies agree dispensed in 90-day quantities to keep you on track
to accept our allowance as payment in full (often less with your medicine and lower your cost. You can choose
than their normal charge). to receive your 3-month supply through Express Scripts
Mail Order prescription program or locally at a
΅ Out-of-Network Pharmacies: If you use a pharmacy that
does not participate, you will have to pay the difference CVS Pharmacy.
between what the pharmacy charges and what the Plan ΅ The National Pharmacy Network includes many chains
pays in addition to any coinsurance or copay and may and independent retail pharmacies nationwide. You will
need to complete and submit a claim for reimbursement. need to use a network pharmacy to receive the
plan benefits.

Visit www.express-scripts.com to find a participating
Pharmacy or call Express Scripts Member Services at
800-903-6228.

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