There are important features you should be aware of. These include:
- Who can write your prescription. A U. S. licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.
- Where you can obtain them. You may fill the prescription at a participating Express Scripts network pharmacy, a non-network pharmacy, the Express Scripts Mail Service, or the Express Scripts Specialty Pharmacy. To receive the Plan's maximum benefit, you must fill the prescription at a participating Express Scripts network pharmacy, through the Express Scripts Mail Service for maintenance medications, or through an Express Scripts Specialty Pharmacy for specialty drugs.
- We use a formulary. Our formulary is the National Preferred Formulary through Express Scripts. The formulary identifies cost-effective medications that have been selected for their clinical effectiveness. By asking your doctor to prescribe formulary medications, you can help reduce your costs while maintaining high quality care. There are safe, proven medication alternatives in each therapy class that are covered on the formulary. Some drugs are excluded from the formulary and coverage. Visit
www.SambaPlans.com/health-benefit-plan/ for a list of excluded medications. This list is not all inclusive and there may be changes to the list during the year. A formulary exception process is available to physicians if they feel the formulary alternatives are not appropriate. Your doctor may request a clinical exception by calling 855-315-8527.
Your copayment or coinsurance amounts are less for drugs listed on the formulary than those that are not.
Our payment levels are categorized as:
Tier 1: generic drugs
Tier 2: formulary or preferred brand name drugs
Tier 3: non-formulary or non-preferred brand name drugs
Tier 4: generic/preferred specialty drugs
Tier 5: non-preferred specialty drugs
- Generic drugs or generic equivalents are medications that have the same active ingredients, and provide the same clinical benefits as their brand-name counterparts. Generic equivalents become available when a brand name drug patent expires. They may look different than their corresponding brand name drugs in size, shape or color, but they meet the same U.S. Food and Drug Administration standards for safety, purity and potency.
- Single source brand drugs are brand name drugs that do not have a generic equivalent which are marketed under a registered trade name or trademark and are available from only one manufacturer. These products are generally patent-protected for a period of time.
- Multisource brand drugs are brand name drugs which are distributed by more than one manufacturer and which also may have a generic drug counterpart available.
- Specialty drugs, including biotech drugs, require special handling and close monitoring and are used to treat chronic complex conditions including, but not limited to: hemophilia, immune deficiency, growth hormone deficiencies, multiple sclerosis, Crohn's disease, hepatitis C, HIV, hormonal disorders, infertility, rheumatoid arthritis, and pulmonary disorders. These drugs may require prior authorization.
You are required to obtain all specialty drugs used for long term therapy (chronic specialty drugs) from Accredo (home delivery), your exclusive Specialty Pharmacy. The Plan will allow two fills at retail for specialty drugs used for short term therapy for the treatment of an acute condition. You will be responsible for the full cost of any short term therapy (acute) specialty drugs after two retail fills and any long term therapy (chronic) specialty drugs purchased at a pharmacy other than Accredo. Note: This does not apply to specialty medications you purchase from a retail pharmacy outside the 50 United States. You file a claim for them as you would for other medications purchased in this manner.
Express Scripts can advise you if your prescription is required to be obtained from Accredo and cannot be obtained from a retail pharmacy. Your physician can fax your prescription directly to Accredo at 800-391-9707 or you can mail your prescription to: Express Scripts, P. O. Box 66577, St. Louis, MO 63166-6577.
Call Express Scripts at 855-315-8527 for prior authorization and if you have any questions regarding quantity limits, or other issues related to their Specialty Pharmacy services.
- Compound Medications are made when a licensed pharmacist combines or mixes multiple ingredients to meet a doctor’s request. The U.S. Food and Drug Administration (FDA) does not verify the quality, safety and/or effectiveness of compound medications. While they may be used if an FDA approved commercially available drug does not work, compound medications have ingredients that can often cost more but are not necessarily more effective than similar FDA-approved medications.
Compounded prescriptions are not FDA approved and not covered under the Plan. Investigational drugs are not FDA approved; therefore, if the compound includes an investigational drug, the compound will not be covered. Your doctor must call Express Scripts Member Services at 855-315-8527 to determine if the compound medication is covered. If coverage is not approved, you will be responsible for the full cost of the compound medication. Ask your doctor to prescribe FDA approved manufactured products for your condition.
If your physician prescribes a new medication that will be taken over an extended period of time and you prefer to receive your maintenance medication through the mail, you should request two prescriptions – one to be used for the participating Express Scripts network pharmacy and the other for Express Scripts Mail Service. You may obtain up to a 30-day supply right away through the prescription card program and up to a 90-day supply from the Express Scripts Mail Service. In addition, you may utilize the Smart90® Program (see above) for your maintenance medications and receive a 90-day supply from select participating pharmacies. In most cases, refills cannot be obtained until 75% of the prescription has been used. Call us or visit our website if you have any questions about dispensing limits.
The Plan will authorize up to a 90-day supply of medication(s) if you should be called to active military duty or a 30-day supply to meet your needs in time of a national emergency.
Benefits for all prescription drugs will be determined based on the fill date of the prescription.
All matters pertaining to the dispensing of covered drugs or the practice of pharmacy in general are subject to the professional judgment of the dispensing pharmacist subject to applicable pharmacy laws.
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a brand name. If you receive a brand name drug when an FDA-approved generic drug is available, you have to pay the difference in cost between the brand name drug and the generic plus the generic copay.
- Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original brand name product. Generics cost less than the equivalent brand name product. The U.S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand name drugs.
You and your doctor have the option to request a brand name drug even if a generic equivalent is available. However, you will be responsible for the difference in cost between the brand name drug and the generic even when the physician indicates "dispense as written" (DAW). Using the most cost-effective medication saves money.
- Patient Safety, Economy and Effectiveness Programs
SAMBA has several programs to promote patient safety, economic and efficacious pharmacy management. These programs work to ensure that safe and appropriate quantities of medication are being dispensed. The result is improved care and safety for our members. These programs include:
- Quantity allowances. Specific allowances are in place for certain medications, based on FDA-approved prescribing and safety information and clinical guidelines. These include but are not limited to quantity limits and refills.
- Drug Utilization Review (DUR). When you fill your prescription at a network pharmacy or through the mail order drug program, we and/or the pharmacist may electronically access information about prior prescriptions, checking for harmful drug interactions, drug duplication, excessive use, and the frequency of refills. DUR helps protect against potentially dangerous drug interactions or inappropriate use. When appropriate, your pharmacist(s) and/or Express Scripts may contact your physician(s) to discuss an alternative drug or treatment option, prescription drug compliance, and the best and most cost-effective use of services. In addition, we may perform a periodic review of prescriptions to help ensure your safety and to provide health education and support. Upon review, we may contact you or your provider(s) to discuss your current medical situation and may offer assistance in coordinating care and treatment.
- Opioid Management Program: This program is focused on significantly reducing unnecessary prescribing, dispensing and use of opioids. The program is designed to lower risk at each touchpoint of the care continuum – including prescribers, pharmacies and patients. The Opioid Management Program is intended to accomplish the following:
- Prevent excess opioid medications from being dispensed by limiting first fill of short-acting opioids to a 7-day supply.
- Encourage safe starts of long-acting opioids through enhanced prior authorization whenever a long-acting opioid is not in the member’s claim history.
- Ensure doses across all opioids are safe and medically necessary.
Specially trained pharmacists will contact patients when they fill: (a) two or more different short-acting opioids within a 30-day period, (b) two or more long-acting opioids within a 21-day period from two or more prescribers, or (c) a combination of three or more different opioids.
- RationalMed Program: This program improves clinical quality through early risk detection and intervention. By review and analysis of integrated pharmacy and medical data, the program helps identify and resolve potential safety issues that increase risk of hospitalizations and adverse events. Once identified, concerns are brought to the attention of the physician.
- Prior authorization: Prior authorization must be obtained for certain prescription drugs and supplies to assess appropriate therapy and drug dosage before providing benefits. In addition to those drugs listed on pages 71 and 72, other medications that require prior authorization include, but are not limited to, anabolic steroids, narcolepsy drugs, topical acne medications, testosterone products, gene therapies, and select pain medications. Also included are the following therapy categories: metabolic/immune diseases, rare diseases, anti-infectives, antifungals, blood disorders, neurological, gastrointestinal, cardiovascular, and ophthalmic.
Our prior authorization review uses Plan rules based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe, and effective.
Other medications might be limited to a certain amount (such as quantity or dosage) within a specific time period, or require authorization to confirm clinical use based on FDA labeling. To find out if your medication requires prior authorization, contact Express Scripts at 855-315-8527.
- SafeGuard Rx Program: This suite of solutions target specific chronic therapeutic conditions. The specific programs achieve better outcomes by focusing on adherence and improving care with an emphasis on ensuring members receive appropriate therapy and specialized care for their condition. Medications used to treat high cholesterol, diabetes, asthma/COPD and multiple sclerosis are examples of targeted therapies.
- Step Therapy: Ensures that a generic alternative or brand alternative within a therapeutic category is used as a first-line treatment, before the use of a similar but more expensive drug. Specific therapeutic categories are identified as appropriate for preferred drug step therapy.
The Plan requires the Step Therapy program for Colchicine, Cox-2 inhibitors, Hypnotics, Nasal Steroids, Nonsteroidal Anti-inflammatory drugs, Ophthalmic antiallergy, Proton Pump Inhibitors, Tetracyclines, Topical Acne/Rosacea, Topical Antifungal, Topical Corticosteroids and Topical Immunomodulators. Also included are the following therapeutic categories: allergies, analgesics, antifungals, anti-infectives, asthma/COPD, attention disorders, blood disorders, bone conditions, benign prostate hypertrophy, constipation, contraceptives, cough and cold, depression, diabetes, endocrine, gout, headaches, hepatitis C, cholesterol, hypertension, inflammatory conditions, migraine, musculoskeletal conditions, nausea and vomiting, mental health, ophthalmic, overactive bladder, pain, Parkinson's, pulmonary arterial hypertension, respiratory conditions, skin, topical inflammatory, transplant, urinary disorders, and ulcer.
The Plan also participates in Step Therapy rules on specialty drugs. Therapies include, but are not limited to: Growth Hormones, Inflammatory Conditions, and Multiple Sclerosis.
In situations where the targeted drug is prescribed, doctors are notified of lower-cost generics and preferred brands. If the doctor approves, the cost-effective medication is dispensed. If the doctor disapproves, a coverage review is initiated. If the coverage review is approved, the member is responsible for the Plan's normal coinsurance (see Covered medications and supplies on page 77). If the coverage review is denied, the member is responsible for the full cost of the drug. If the member does not first obtain the Plan’s approval, they will pay the full cost of the drug. If approval is obtained after filling the prescription, the member may be reimbursed for any amount they paid minus their normal coinsurance. Coverage reviews can be initiated by the member, pharmacist, or doctor by calling Express Scripts at 855-315-8527.
Contact Express Scripts at 855-315-8527 for additional information regarding patient safety, economic or effective management programs listed above.
- To claim benefits.
- From a pharmacy – When you purchase medication from a network pharmacy use your SAMBA/Express Scripts Identification Card. In most cases, you simply present the card, together with the prescription, to the pharmacist; the claim is automatically filed through the Express Scripts system.
If you do not use your identification card when purchasing your medication, or you use a non-network or overseas pharmacy, you must submit a direct reimbursement claim form with supporting documentation to claim benefits. You can submit this form online by logging in to your account at www.express-scripts.com and locating the "Submit your claim online" link on the Forms and Cards page. You may also obtain these forms by calling Express Scripts toll-free at 855-315-8527 or by visiting the SAMBA website at www.SambaPlans.com/health-benefit-plan/. Service is available 7 days a week, 24 hours a day. Follow the instructions on the form and mail it to:
Express Scripts
Attention: Commercial Claims
P. O. Box 14711
Lexington, KY 40512-4711
Note: Reimbursement will be limited to SAMBA's cost had you used a participating pharmacy minus the copayments described under Covered medications and supplies on page 77.
- By mail – The Plan will send you information on Express Scripts Mail Service:
1. Ask your doctor to give you a new prescription for up to a 90-day supply of your regular medication plus refills, if appropriate;
2. Complete the patient profile/order form the first time you order under the program; and
3. Complete a mail order envelope, enclose your prescriptions, and mail them along with the required copayment for each prescription or refill to:
Express Scripts Home Delivery Service
P. O. Box 66577
St. Louis, MO 63166-6577
You must pay your share of the cost by check, money order, VISA, Discover, or MasterCard (complete the space provided on the order envelope to use your charge card).
You will receive forms for refills and future prescription orders each time you receive drugs or supplies from Express Scripts Mail Service. In the meantime, if you have questions about a particular drug or a prescription, and to request your first order forms, you may call 855-315-8527 toll-free. Customer service is available 7 days a week, 24 hours a day. You may also download order forms from www.express-scripts.com.
Note: As at your local pharmacy, if you request a brand name prescription when a generic equivalent is available, you will be responsible for the difference in price between the brand name drug and its generic equivalent.
- Coordinating with other drug coverage.
If you have other prescription drug coverage and the other insurance carrier is primary, you should use that carrier's prescription drug benefits first. When purchasing your covered medications from a retail pharmacy, follow your primary insurance carrier's instructions on how to file a claim. After their consideration, submit the claim along with the primary carrier's explanation of benefits (EOB) directly to Express Scripts.
If you elect to use Express Scripts Mail Service, you will be billed directly for the full discounted cost of the covered medication. Pay Express Scripts Mail Service the billed amount and submit the bill to your primary insurance carrier. After their consideration submit the claim and the primary carrier's EOB to Express Scripts at:
Express Scripts
Attention: Commercial Claims
P. O. Box 14711
Lexington, KY 40512-4711
- For Medicare Part B insurance coverage.
Prescriptions typically covered by Medicare Part B include diabetes supplies (test strips, meters), specific medications used to aid tissue acceptance from organ transplants, certain oral medications used to treat cancer, ostomy supplies, and various inhalants used in nebulizers (devices that deliver liquid medication in mist form). Some Medicare Part B medicines and supplies (such as for diabetes) may not be available through the Express Scripts Mail Service. If Medicare Part B is primary, discuss with the retail pharmacy and/or Express Scripts Mail Service the options to submit Medicare covered medications and supplies to allow Medicare to pay as the primary carrier.
When using a retail pharmacy for eligible Medicare Part B medication or supplies, be sure to present your Medicare ID card. If your medication or supplies are eligible for Medicare Part B, the retail pharmacy will submit your claim to Medicare for you. Most independent pharmacies and national chains are Medicare providers. To find a retail pharmacy that is a Medicare Part B participating provider, visit the Medicare website at www.medicare.gov/supplier/home.asp or call Medicare Customer Service at 800-633-4227.
- Medicare Part D insurance coverage
SAMBA supplements the coverage you get with your Medicare Part D prescription drug plan. Your Medicare Part D drug plan will provide your primary prescription drug benefit and SAMBA will provide your secondary prescription drug benefit. To ensure that you get all the coverage you are entitled to receive, use a pharmacy that participates in the networks for both SAMBA and your Medicare Part D plan. Show both the Medicare Part D ID card and the SAMBA ID card when filling a prescription so the pharmacy can coordinate coverage on your behalf.
