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Prescription medications

Prescription medications

Our medical plan provides comprehensive prescription coverage, administered by Express Scripts and ArchimedesRx. By choosing in-network pharmacies and generic medications, you’ll keep more dollars in your pocket.

Show your OhioHealthy ID Card at the pharmacy to make sure you receive any discounts, and that the prescription cost counts toward your deductible and out-of-pocket maximum.

Visit Express-Scripts.com to see whether a medication is covered, find the Formulary/Prescription Drug List (updated quarterly), research prices, and locate an in-network pharmacy. You'll need to register at Express-Scripts.com to manage your account online.

For a full list of medications covered by Archimedes, call 888-504-5563 or log into your member portal at Archimedesrx.com. Medications covered through Archimedes include antiviral medications, transplant medications and specialty medications.

Good to know

Formulary/Prescription Drug List (PDL)	A list of medications covered by your medical plan, organized into tiers - the higher the tier, the higher the cost of the medication. This list is updated quarterly. If you are prescribed a medication, check to see if it appears on this list; if not, discuss the possible alternatives with your healthcare provider to save money.
Mandatory generic	If you choose a brand name medication when a generic is available, you will pay the coinsurance, plus the cost difference between the two drugs (the difference does not count toward your deductible or out-of-pocket maximum).
Specialty medication	A medication that requires special handling, administration or monitoring — typically one used to treat complex conditions. Prescriptions for these must be filled through OhioHealth Specialty Pharmacy or Archimedes. Call OhioHealth Specialty Pharmacy at (614) 566.5115 or Archimedes at (888) 504.5563 or log into your member portal at Archimedesrx.com.
Step therapy	For some medical conditions, there are drugs with similar clinical effectiveness but wide variation in price. You may need to try a 'step 1' medication before a 'step 2' medication is covered.
Prior authorization	Some medications require prior authorization before a prescription can be filled. Your doctor or your pharmacist will let you know if you need prior authorization.
Quantity limits	Some medications have quantity limits to promote the appropriate use of medications, prevent waste and help control costs.
Medication therapy management - targeted medication reviews	A double check by a pharmacist to ensure your medication plan is the best that it can be, including lowering the risk for potential drug related problems, providing helpful tips for taking your medications, and identifying ways to reduce medication costs. A pharmacist may call you or send you a letter in the mail if they have recommendations to improve your medication therapy. Participation is voluntary and does not change your drug coverage. If you have questions about this benefit or do not want to participate in targeted medication reviews, please call (614) 788-9355.
Maintenance medications/90-day supplies	Some medications that are taken regularly or for an ongoing condition are called maintenance medications. (You do not need to follow the maintenance medication requirement if your medication is a specialty medication.) You have the option of filling a three-month supply of your maintenance medication at any in-network retail pharmacy.
Using coupons	Drug manufacturers often issue coupons to encourage continued use of a more expensive brand name drug, even though less expensive similar or equivalent options have become available. Note that the coupon value is often counted toward your deductible, even though you are not paying that amount out-of-pocket. This may have tax reporting implications for you. Archimedes will help you apply for coupons when available so you can take advantage of these savings. If you fill a prescription for a specialty drug and use a manufacturer copay assistance program to reduce your out-of-pocket cost for the drug, only the actual amount you pay will count toward your deductible and out-of-pocket maximum.
Diabetes and Asthma	If you’re enrolled in our medical plan and are actively participating in the OhioHealth disease management program for Diabetes or Asthma, you may qualify to have certain medications paid for at 100%. (If you are enrolled in the OhioHealthy HDHP+HSA, you will need to meet your deductible first.)

How much does this benefit cost?

Prescription coverage is included in your medical plan premiums. The way you pay for prescription medications depends on the medical plan option you choose:

OhioHealthy HDHP: You pay the full cost of covered medications until you meet your deductible. Then, the plan pays 90% of the cost of most covered medications, and you pay 10%. You may use your HSA funds to pay for medications.
OhioHealthy PPO: There is a separate per person prescription drug deductible to meet for Tier 1 medications. It's $100 for Associate Only coverage, $200 for Associate + 1, and a maximum of $300 for Associate + 2 or more. Each member pays the full cost of covered medications in Tier 1 until their deductible is met. Then you will pay a flat copay for covered medications in Tier 1 after you meet the deductible. For all other tiers, there is no separate deductible to meet and you will pay only coinsurance for covered medications.
OhioHealthy PPO Assist: There are flat copays or coinsurance for different tiers of medication; there is no deductible to meet.

How to make the most of this benefit

Ask your healthcare provider for generic medication or one listed on our Formulary/Prescription Drug List that might work for you
Download the Express Scripts app so you can discuss medication options with your healthcare provider on-the-go during your consultation
Use the Express Scripts website or app to research the cost of a medication at different pharmacies (you must use OhioHealth Specialty Pharmacy or Archimedes for specialty medications), see lower-cost alternatives and explore pricing for different dosage options (for example, occasionally two 50mg capsules can cost less than one 100mg tablet)
Follow all instructions and take your medications according to the prescribed schedule
Call your physician or pharmacy if you have questions or any concerns about drug interactions
Combine this benefit with a Health Savings Account (HSA) or Healthcare Flexible Spending Account (Healthcare FSA) to get eligible out-of-pocket expenses reimbursed
If you have an HSA or Healthcare FSA, use your debit card to pay for your prescription medicines and save your receipts on the HealthEquity mobile app