The prescription drug program

The MPO covers outpatient prescription drugs only if you are not enrolled in a Medicare Part D plan. The MPO's prescription drug benefits offer cost-saving ways to buy outpatient prescription drugs:

• A network of local participating retail pharmacies for short-term prescriptions.
• Express Scripts Pharmacy, the home delivery pharmacy, and participating Smart90 retail pharmacies (e.g. Walgreens, CVS) for long-term or maintenance prescriptions.
• Express Scripts Specialty Pharmacy, Accredo, for prescriptions requiring special handling.

No deductible is required.

A vaccine program is available at participating network pharmacies through Express Scripts (www.expressscripts.com), in addition to current coverage available through physician/medical facilities:

• Members may conveniently receive common vaccinations at their retail pharmacy at no cost. Coverage includes vaccines such as COVID-19, Flu, Hepatitis A, B and A&B, Pneumonia, Shingles/Zoster, Meningitis, Tetanus/Diptheria/Pertussis, Human papillomavirus (HPV), etc.
• Shingles Vaccine: Zostavax and Shingrix are both covered under your prescription drug plan. For more information contact Express Scripts 1-800-695-4116. You can also visit www.express-scripts.com. For vaccines where there is a member cost share, the copay structure is the same as it is for other branded medications:Retail Brand 30% max $125.
• Members are not required to provide a prescription to receive vaccines.
• Members will need to present their prescription ID card to ensure that the vaccine is processed under the pharmacy benefit.

Note: Prescription medications, including injections, billed by and provided in a hospital or a doctor's office are typically not covered under the prescription drug program but may be covered medical expenses under the MPO. For more information please refer to the Schedule of Cost Sharing (SOC) in the ExxonMobil Aetna Medicare website. Medications billed to you by Express Scripts are not covered under the medical portion of the MPO.

For certain prescription drugs:

You must call Express Scripts for prior authorization of certain prescription drugs. 

In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the MPO will cover another drug.

Additionally, as part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless pre-authorized by Express Scripts, based on medical evidence submitted by your physician.

Non-targeted drugs are covered without prior authorization. Refer to the Prescription drug program section for more details.

You must identify yourself as a member of the Express Scripts retail pharmacy program to receive the benefit.

Call Express Scripts at 800-695-4116 or check the Express Scripts web site at www.express-scripts.com to locate a participating retail pharmacy near you.  

Short-term prescriptions

A short-term prescription is written for a drug taken for a limited period of time, such as an antibiotic for a specific illness or if your doctor wants you to try the prescription before having a long-term prescription filled. Short-term prescriptions are provided for up to a 34-day supply. See Covered prescriptions for limitations.

You have the choice of filling your prescriptions at:

• A local participating retail pharmacy (part of Express Script's extensive network of retail pharmacies), where you will pay your share — copayment — of the discounted cost. There are no claims to file.
• A non-participating pharmacy of your choice, where you will pay the full retail price and file a claim for partial reimbursement of the cost.

To receive the discounted price:

• Present your prescription and either your prescription drug identification card or the primary participant's identification number at a participating network pharmacy.
• The pharmacist enters the prescription and the primary participant's identification number into the pharmacy's computer system to confirm:
• That you are a participant or family member covered by this option.
• That it is a covered prescription.
• Your share of the prescription's cost.

The term primary participant refers to the participant whose identification number is used for identification purposes. The primary participant is the retiree, survivor, or individual who elected COBRA coverage. Covered family members use the primary participant's identification number to access all medical and pharmacy benefits. Be sure to give identification cards or the primary participant's identification number to your eligible family members. 

Refills

You may order refills by calling Express Scripts or sending in the refill label provided with your previous order. You may also order refills through Express Scripts’ website. You should order a refill about three weeks before your current supply will be exhausted, but remember that you must have used about three quarters of the previous prescription based on the prescribed dosage.

Copayments

	Short Term Retail Pharmacy Co-Pay* ** *** ****		Long Term Express Scripts, or Smart90 Pharmacy
	(up to 34-day supply)	Maximum Per Prescription 3rd+ Retail Refill****	(up to 90-day supply)	Maximum Per Prescription
Generic Drugs	30%	$50	25%	$100
Formulary Brand Drugs	30%	$125	25%	$250
Non-Formulary Brand Drugs	50%	$200	45%	$400

*If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail copays.

** If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic copay and the full difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand and the generic does not apply to the annual out-of-pocket maximum for prescription drugs.

*** You must present your Express Scripts Prescription Card or identification number of the primary participant or benefits will be paid at the non-network level.

**** Preferred means Express Scripts’ formulary of preferred prescription drugs. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance and is included in the drug list linked here, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, a 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.

Prescription drugs — Annual out-of-pocket (OOP) maximums for prescription drugs--$2,500/individual (out-of-network prescription claims will go towards your OOP maximum but only at the value/rate that would have been paid had an in-network provider been utilized).

For short-term prescription drugs purchased at a participating retail pharmacy, you pay a percentage of the discounted cost of the drugs.

Examples:

Generic short-term drug purchased at a retail network pharmacy — discounted cost of medication is $24.

You pay 30% copayment ($24 x .30) = $7.20

Preferred brand name short-term drug purchased at a retail network pharmacy (if no generic is available) — cost of medication is $42.

You pay 30% copayment ($42 x .30) = $12.60

Non-preferred brand name short-term drug purchased at a retail network pharmacy (if no generic is available) — cost of medication is $64.

You pay 50% copayment ($64 x .50) = $32

Short-term retail refill limitation for maintenance medications

A long-term or maintenance medication is a drug you take for an extended period of time, such as for the ongoing treatment of diabetes, arthritis, a heart condition, or blood pressure. After the third short-term fill of a maintenance medication at a participating or non-participating retail pharmacy, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (e.g. Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term or maintenance medication after the third fill, you will be responsible for 100% of the cost.

Using a non-participating pharmacy or not identifying yourself as an Express Scripts participant

You are not eligible for a discounted price if you:

• Have your prescription filled at a non-participating pharmacy, or
• Do not identify yourself as an Express Scripts participant at a network pharmacy.

In either case:

• You pay the full non-discounted price of the prescription at the time of purchase.
• You must submit a completed Direct Reimbursement Claim Form to Express Scripts. You may obtain a claim form by calling Express Scripts at the number shown in the front of this SPD.
• You will be responsible for 100% of the difference between the non-discounted and discounted cost of the prescription (the ineligible cost) plus your percentage copayment portion of the discounted cost.

This example shows how you would save money when you use a network pharmacy and show your prescription ID card. In this case, you would save $10.

	Without Express Scripts Discount	With Express Script Discount
Full retail cost of preferred brand name prescription (non-discounted) Discounted cost Ineligible cost	$ 50.00 - $ 40.00 $ 10.00	N/A $ 40.00 0.00
Ineligible cost 30% copayment ($40 x .30)	$ 10.00 $ 12.00	$ 0.00 $ 12.00
Your cost	$ 22.00	$ 12.00

Long-term prescriptions

A long-term or maintenance drug is one you take for an extended period of time, such as for ongoing treatment of diabetes, arthritis, heart condition, or high blood pressure. The MPO generally provides benefits for up to a 90-day supply through a participating Smart90 retail pharmacy (e.g. Walgreens, CVS) or Express Scripts home delivery pharmacy. See Covered prescriptions for limitations.

If you need maintenance medication immediately, ask your doctor for two prescriptions — one for an immediate supply to be filled at a local pharmacy and a second for an extended supply to be ordered by mail or at a Smart90 retail pharmacy. 

After the third short-term fill of a maintenance medication at a participating or non-participating retail pharmacy, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (e.g. Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term or maintenance medication after the third fill, you will be responsible for 100% of the cost.

Express scripts pharmacy — home delivery pharmacy

With Express Scripts Pharmacy, the home delivery pharmacy, you save money and have the convenience of home delivery. Ask the doctor to write a prescription for up to a 90-day supply with appropriate refills. Enclose your original prescription(s) and payment of your percentage copayment in an envelope, or your doctor may send the prescription electronically directly to Express Scripts. If you are paying via check or money order, you may obtain a calculation of your percentage copayment from the Express Scripts web site or by calling Express Scripts directly. If you are paying via credit card, Express Scripts will deduct the appropriate percentage copayment, and you will receive notification of the deduction with your medication.

For each prescription filled, you pay:

Type of Drug	Express Scripts Pharmacy Percentage Copayment
Generic drugs	25%
Preferred brand name drugs	25%
Non-preferred brand name drugs	45%

Your prescription will be delivered to the address on your order form within 14 working days. By law, prescriptions may not be sent outside the U.S.

Refills

You may order refills by calling Express Scripts or sending in the refill label provided with your previous order. You may also order refills through Express Scripts website. You should order a refill about three weeks before your current supply will be exhausted, but remember that you must have used about three quarters of the previous prescription based on the prescribed dosage.

You can also fill or refill a long-term prescription at a participating Smart90 (e.g. Walgreens, CVS) retail pharmacy.

Comparing retail pharmacy with Express Scripts Pharmacy

This example shows how you can save money by purchasing long-term medications through either the Express Scripts home delivery or a Smart90 retail pharmacy.

Assume you purchase a 90-day supply of a preferred brand name drug:

At a Participating Retail Pharmacy:		Through Express Scripts, or Smart90 Pharmacy:
$ 108.00	Cost of preferred brand name drug (30-day supply)	$ 324.00	Cost of preferred brand name drug (90-day supply)
x 30%	Percentage copayment	x 25%	Percentage copayment
$ 32.40	Your copayment for a 30-day supply or $97.20 for a 90-day supply	$ 81.00	Your copayment
You pay $97.20 for a 90-day supply		You pay $81.00 for a 90-day supply

By purchasing a 90-day supply of this prescription through Express Scripts home delivery or at a Smart90 retail pharmacy, you would save $16.20. That is $64.80 a year for one prescription.

Whether you fill prescriptions through Express Scripts Pharmacy, at a local pharmacy or through Express Scripts Specialty Pharmacy:

• Your payments and copayments under the outpatient prescription drug benefits do not apply toward your deductible for other benefits under the MPO.
• Your prescription drug payments and copayments do not apply toward your annual medical out-of-pocket limit.
• Your prescription drug annual out-of-pocket maximum is $2,500 for each individual in your family, or $5,000 for your entire family.
• The additional cost for purchasing brand-name prescription drugs when a generic is available, as well as the full cost for purchasing subsequent refills of maintenance medications after the third fill obtained at retail pharmacies that are not part of the Smart90 network (e.g. Walgreens, CVS), will not count toward your annual out-of-pocket maximum. 

	Short-Term Per Prescription Out-of-Pocket Maximum (30-day or less supply)	Long-Term Per Prescription Out-of-Pocket Maximum (Generally 90-day or less supply)
Generic	30% with a $50.00 max	25% with a $100.00 max
Preferred brand name drugs	30% with a $125.00 max	25% with a $250.00 max
Non-preferred brand name drugs	50% with a $200.00 max	45% with a $400.00 max

 

Covered prescriptions

The MPO covers drugs, medicines and supplies that are:

• Obtainable only with a physician's prescription, or are specifically covered expenses(see Covered expenses).
• Approved by the U.S. Food and Drug Administration for the specific diagnosis.
• Not experimental or investigational. 
• Prescription smoking deterrent medications.
• Outpatient prescription drugs unless you are enrolled in Medicare Part D.

Generic drugs

The program encourages consideration of generic alternatives, which are less expensive to you and the MPO. The majority of brand name medications have a generic equivalent available. By law, the brand name and generic medications must meet the same standards for safety, purity, strength, and effectiveness. The pharmacist will only dispense generics which receive FDA approval and only if authorized by your doctor.

Note: If both generic and brand name drugs are available to treat your condition, your percentage copayment amount will depend on which medication you select. If you purchase the brand name drug, you are responsible for paying the generic drug percentage copayment PLUS the full difference in cost between the generic drug and the brand name drug. This difference in cost will not count toward your annual prescription drug out-of-pocket maximum.

Here is an example of how you can save by choosing a generic drug at a retail pharmacy when a brand-name drug is available on the MPO's formulary list of medications.

Cost Difference between Brand and Generic			Percentage Copayment
$100.00	Cost of preferred brand-name drug (30-day supply)		$50.00	Cost of generic drug (30-day supply)
$50.00	Cost of generic drug (30-day supply)		x 30%	Percentage copayment
$50.00	Cost difference		$15.00	Your copayment if you purchase the generic
*If you purchase the brand name drug: Your copayment will be $15.00 + $50.00 (cost difference) = $65.00 The additional $50 does not count toward your annual prescription drug out-of-pocket maximum.

Available alternatives

Sometimes, a generic drug or a less expensive brand name drug which provides the same therapeutic effect, but at a lower cost to you, may be available. If so, the network system will inform the pharmacist that a less expensive alternative medication is available to fill your prescription. A pharmacist from the network or Express Scripts Pharmacy may contact your doctor to discuss the generic or less expensive brand name alternative. If the doctor authorizes a substitution, the pharmacist will dispense it based solely on your doctor's agreement. If Express Scripts Pharmacy fills a prescription with a generic or an alternative brand name drug, your order will include an explanation of the doctor's change and a credit for any excess copayment.  

The network formulary program

A formulary is a list of commonly prescribed medications within particular therapeutic categories. The drugs on the list have been selected based on their effectiveness and cost. To be included in the formulary list, a drug must meet rigorous standards of approval by the Express Scripts Pharmacy and Therapeutic Committee - a group of nationally recognized medical professionals.

It is always up to your doctor to decide which medications to prescribe. If you have questions about the Express Scripts formulary, you should contact Express Scripts directly.

Drug monitoring service

All prescriptions, both home delivery and retail, are screened by the network's computerized drug monitoring service.

This service analyzes all of your prescriptions in the system for potential problems such as adverse drug interactions, drug duplications, and unusually high or low dosages. This service will also detect if a refill is requested too soon. If a potential problem is detected, the drug monitoring service transmits a message to the pharmacist. The pharmacist will contact your doctor about the potential problem or otherwise resolve the issue before dispensing the prescription. Of course, your doctor makes the final decision about any change in your prescription or course of treatment.

Limitations

In most cases, the pharmacist will fill the prescription according to the doctor's written orders. However, there are some limitations:

• If the prescription is written for an amount that is greater than the MPO covers, the pharmacist will fill the prescription up to the MPO limit. You have the option to buy the additional amount at that time if purchasing at a retail pharmacy, but there is no MPO benefit.
• If the medicine is a controlled substance or if there is a manufacturer's or prescription benefit manager's directive, a smaller amount may be provided.
• For most prescriptions, you must use about three quarters of the previous prescription, based on the dosage prescribed, before you can obtain a refill and receive MPO benefits.
• During natural disasters, you may be able to replace lost or damaged medications without having used 75% of the previous prescription.

Special rules for coordinating benefits for prescriptions

If you or your family members are covered under any other group medical plan, the MPO coordinates benefits with that plan, as described in the Coordination of benefits section of this SPD. In addition, information about the other coverage is provided to the outpatient prescription drug network.

When a pharmacist reviews your family member's eligibility information in the network system, a code will indicate if your family member has other coverage that should pay benefits first. In these cases, you must first pay according to the primary plan provisions (i.e., you cannot purchase prescriptions using the Express Scripts card or through the home delivery prescription service). After the primary plan has paid, you may file a claim with the MPO for reimbursement of any remaining amount; the procedure is the same as when a non-participating pharmacy is used. The MPO will pay the lesser of what would have been paid if the claim was not filed with the primary plan or the amount not paid by the primary plan.

Medicare Part D and the Prescription Drug Program

Participants who choose to enroll in an individual Medicare Part D prescription drug plan will no longer be eligible for coverage under the MPO. However, a participant can be enrolled in an Employer Group Waiver Plan (EGWP) Part D plan.

Specialty medications

Specialty medications, including injectable and infusions for rheumatoid arthritis and other inflammatory conditions, require special handling and may be administered in a hospital, clinic, doctor’s office, or in your home. Some specialty medications, like most oncology drugs administered in a hospital setting, are covered under the medical benefit administered by Aetna. Other specialty medications are covered under the prescription drug program administered by Express Scripts. If you have questions about starting a specialty medication, call Aetna member services and ask to speak to a Health Advocate nurse.

Specialty medications administered by Express Scripts are filled through their specialty pharmacy Accredo and can be delivered to hospitals, clinics, doctor’s offices, or to a home health care provider. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance and is included in the drug list linked here, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, a 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.

Advanced utilization management program

In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the MPO will cover another drug. Prior authorization and preferred drug step therapy rules are designed to encourage the use of effective, lower-cost drugs.

As part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless pre-authorized by Express Scripts, based on medical evidence submitted by your physician. In addition, some therapies will be monitored for appropriate pharmacogenomics parameters, and oral oncology medications will be limited to ensure appropriate use. Please visit www.express-scripts.com for more information about your medications and if they require a coverage review.  If you have a question regarding a drug on the AUM program list, contact Express Scripts at the number listed in the Information Sources section of this SPD.

Prior authorization: preferred drug step therapy rules

You must call Express Scripts for prior authorization of certain prescription drugs described below:

Preferred drug step therapy rules are used for certain therapeutic chapters of drugs, to encourage the use of effective, lower-cost drugs by excluding some targeted medications from coverage. In the therapeutic chapters including: proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, migraine growth hormone, stimulants for Attention Deficit Hyperactivity Disorder, prostate therapy drugs, topical steroids, and stroke prevention, there will be targeted drugs determined by Express Scripts which will not be covered unless pre-certified by Express Scripts. Non-targeted drugs will be covered without such authorization and will continue to be dispensed with no further action by either you or the prescribing physician. If you have a question regarding a drug in any of these therapeutic chapters, contact Express Scripts to determine whether your drug is covered. You will be notified directly by Express Scripts if you are affected by these rules.

Prior authorization rules 

New prior authorization rules apply to certain therapeutic classes of drugs; some therapies in this section will be monitored for appropriate pharmacogenomics parameters. These classes include miscellaneous immunological agents, central nervous system/miscellaneous neurological therapy, biotechnology/adjunctive cancer therapy, central nervous system/headache therapy, central nervous system/analgesics, neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary agents. In addition, anabolic steroids, high cost antibiotics, anti-emetics, antivirals, narcotics, acne dermatological and topical pain medications may trigger a prior authorization. Oral oncology medications will also be limited to ensure appropriate use. Certain drugs within each chapter as determined by Express Scripts will only be covered to the extent they are authorized by Express Scripts. If you have a question regarding coverage for a drug in any of these therapeutic classes, contact Express Scripts. You will be notified directly by Express Scripts if you are affected by these rules.

Therapeutic Resource Centers

MPO participants and their physicians may receive outreach calls from Express Scripts Therapeutic Resource Center (TRC) pharmacists or healthcare specialists to offer personal over-the-phone guidance as well as other health management tools. You can also ask to speak to a TRC pharmacy specialist when you call Express Scripts.

Split-fill program

Express Scripts’ split-fill program applies to certain select specialty conditions where participants often stop or change therapy early in treatment due to side effects or their ability to tolerate treatment. This program will provide smaller initial fills (15-day supply) and clinical support to participants as they begin their therapy. Coinsurance and per prescription maximum will be applied on a prorated basis so that the participant will not be disadvantaged financially. This program is designed to help manage side-effects, eliminate wasted medications, and manage specialty drug costs.