Prescriptions
Benefits Enrollment & Changes
You may enroll in benefits during your first 31 days of full-time employment. However, once elections have been submitted, you are unable to make changes even if you are still within your 31-day enrollment window. You may also make changes to current coverage within 31 days of the date you experience a qualified change in status or change coverage during the annual open enrollment period. Open Enrollment is typically held November 1 – 15 each year, and elections made during this period become effective January 1 of the next calendar year.
Prescription Drug Coverage / Express Scripts
Changes for 2024:
Changes to the Express Scripts National Preferred Formulary Drug List for 2024
Gene Therapy drugs covered through Cigna, not Express Scripts, starting 1/1/24
Vaccine coverage is included in your prescription coverage with Express Scripts in addition to your medical benefit with Cigna. This means you can receive your vaccines from an in-network pharmacy or doctor’s office. Covered vaccines include Flu (injectable and nasal), Pneumonia, Hepatitis, Zoster (shingles), COVID, HPV, Childhood Vaccines (MMR, etc.), Meningicoccal, Tetanus/Diphtheria/Pertussis, and Rabies (prior authorization required).
Patient Assurance Program for Certain Glucose-Lowering Medications:
The Express Scripts’ Patient Assurance Program sets copay limits on certain preferred brand glucose-lowering drugs and products at a $25 copay for up to a 31-day supply or $75 for a 90-day supply. Visit www.express-scripts.com to use the “Price a Medication” tool or call Express Scripts at 800.953.3379 for additional information about the Patient Assurance Program.
Preferred Formulary Changes for 2024:
Medications are added, removed, and changed from one tier level to another on the National Preferred formulary each year. To find out if there will be changes to coverage in 2024 for any medications you are currently receiving, click here: 2024 National Preferred Formulary Medications.
In certain instances, when Express Scripts has identified and excluded high cost drugs with limited clinical value that have clinically-appropriate, lower cost alternatives available, they will send a notice to anyone who is currently taking this medication to let you know it will no longer be covered.
Preventive Drugs Covered 100%
The Affordable Care Act (ACA) requires certain medications to be classified as Preventive Drugs and covered by the plan at 100% with no cost to the member, such as aspirin; contraceptives; certain immunizations; supplements such as folic acid, vitamin D, or prenatal vitamins; bowel preps; smoking cessation products; breast cancer preventive drugs (brand drugs Tamoxifen, Raloxifene, Soltamox or generic anastrozole and exemestane); HIV Pre-Exposure Prophylaxis antiretroviral therapy for those who meet high-risk criteria; and low-to-moderate doses of generic statins (cholesterol-lowering) drugs. Note: if you take a high dose generic or brand name version of a statin medication you will pay the standard coinsurance as described below.
Patient age, drug dosage type and strength criteria must be met for all of these medications. A coverage review must be requested by the patient or doctor and approved by Express Scripts for breast cancer preventive drugs, before $0 copay will be applied.
Deductible Waived For Certain Preventive Drugs
The deductible will be waived for most medications taken to treat the following conditions (Referred to as Preventive Plus):
The following anti-depressents: CELEXA (citalopram), fluvoxamine, LEXAPRO (escitalopram), PAXIL (paroxetine), PAXIL CR (paroxetine ER), PEXEVA, PROZAC (fluoxetine), PROZAC WEEKLY (fluoxetine), SARAFEM (fluoxetine), ZOLOFT (sertraline)
Asthma
Bone Disease and Fractures
Cavities
Colonoscopy Preparation
Diabetes
Insulin and Non-Insulin Medicines
Diabetic Supplies Including Test Strips, Syringes, Needles, and Lancets
Heart Disease and Stroke
Blood Thinner Medicines
Cholesterol Lowering Medicines
High Blood Pressure
Respiratory Syncytial Virus
Malaria
Obesity
These medications are taken to prevent certain medical diagnoses from developing into more serious medical conditions such as heart disease or stroke. Medications to treat these diagnoses are not covered at 100%, as the ACA required preventive medications are; however, we are permitted to waive the annual deductible for these drugs.
To see if your medications are on the Preventive Plus Drug List, Click Here: 2024 Preventive Plus Drug List.
Hypertension Program
This program through Livongo will be available for those enrolled in the Maritz medical plan who have been diagnosed with Hypertension (high blood pressure). The Livongo for Hypertension Program is a health benefit that makes living with high blood pressure easier by providing you with a free cellular connected blood pressure monitor, a mobile app that gives personalized feedback, and one-on-one coaching. The monitor automatically sends your readings to the easy-to-use app. You will receive useful information and tips to help you stay on track managing your blood pressure and feeling your best. Livongo coaches provide answers to your questions and advice on improving your health. You are eligible to opt-in to this program at no cost to you.
Express Scripts will notify Livongo of all covered members who have had at least one claim through the Maritz prescription drug program for hypertension medication. Livongo will send outreach communications to you inviting you to enroll in the program. You can also contact Livongo directly to register and opt in to the program once you are enrolled in the Maritz medical plan at ready.livongo.com/MARITZ/hi or call the Member Support Call Center at (800) 945-4355 for additional information. When prompted for the Client Specific Registration Code, enter Maritz.
Diabetes Care Program
For those enrolled in the Maritz medical plan who have been diagnosed with Diabetes, we want to help you monitor your condition and remain adherent with your medication. You are eligible to opt-in to this program through Livongo at no cost to you. Once enrolled, you receive the following:
Free Livongo cloud connected smart glucose meter
Remote monitoring with real-time (within 3 minutes) outreach driven by dangerous readings via phone, text and email
Coaching by Livongo Certified Diabetes Educators and Express Scripts Diabetes Specialty Pharmacists
Free unlimited Livongo InTouch® strips and lancets
Mango Health app to help you stay engaged and earn rewards
Express Scripts will notify Livongo of all covered members who have had at least one claim through the Maritz prescription drug program for diabetic supplies or medication. Livongo will send outreach communications to you inviting you to enroll in the program. You can also contact Livongo directly to register and opt in to the program at join.livongo.com/MARITZ/hi or call the Member Support Call Center at (800) 945-4355 for additional information. When prompted for the Client Specific Registration Code, enter Maritz.
SaveonSP Program
Maritz partners with Express Scripts SaveonSP program to help members save money on certain specialty medications. If you participate in this program, approximately 150 select specialty medications will be free of charge ($0). These prescriptions will continue to be filled through Accredo, your existing specialty mail pharmacy. If you are currently taking or will be taking one of these medications, you are eligible to participate in this program.
Enrollment in the program is voluntary. Keep in mind that if you choose not to participate, you will be responsible for a significantly higher cost, which will not be applied to your deductible or out-of-pocket maximums.
Express Scripts will send a letter to all members who are currently receiving any prescriptions from Accredo that are included in the SaveonSP program, which will include information about the program and steps to enroll.
If you currently receive specialty medications through Accredo and want to see if they are part of this program, click here: SaveonSP Medications. Medications on this list highlighted in green will be newly added and those highlighted in red will be removed from SaveonSP as of July 1, 2024.
Copayments/Coinsurance
The member coinsurance amount for all drugs is subject to minimum and maximum amounts after the deductible has been waived or satisfied, except for medications on the ACA Preventive or Preventive Plus lists, or medications you receive through SavonSP. See the chart below.
|
|
Generic |
Preferred Brand |
Non-Preferred Brand |
|||
|
Coinsurance % |
20% |
30% |
40% |
|||
|
Min & Max Copays apply after deductible is satisfied or waived |
Retail (30 Days) |
Mail Order (90 days) |
Retail (30 Days) |
Mail Order (90 days) |
Retail (30 Days) |
Mail Order (90 days) |
|
Minimum Copayment |
$10 |
$25 |
$25 |
$60 |
$50 |
$125 |
|
Maximum Copayment |
$30 |
$75 |
$75 |
$180 |
$150 |
$375 |
If your medication is on the Preventive Plus list, in addition to waiving your deductible, you will pay the applicable coinsurance percentage listed above for your medication, subject to the minimums and maximums listed above.
If your medication is not on the Preventive Plus list, you will continue to pay 100% of the cost of your medication until your annual deductible is satisfied. However, once the deductible is satisfied, your cost will be 20% (generic), 30% (preferred brands), or 40% (non-preferred brands), subject to minimums and maximums.
If you have prescriptions filled through Accredo (Express Scripts’ Specialty drug pharmacy), you will need to satisfy your annual deductible before the plan will pay any portion of these medications, unless your medication is on the SaveonSP Drug list (see prior section called “SaveonSP Program” above).
If you do not qualify for any copay assistance programs and are struggling to pay for a full 90-day supply of home delivery medications, contact Accredo or Express Scripts to see if you are able to pay for your 90-day supply of medication in three monthly payments.
Please note that the value of manufacturer coupons does not count toward your deductible and out-of-pocket maximum. Only the amount you pay out of your own pocket, or from your HSA, will apply.
Mail Order Requirement
The plan requires most maintenance medications to be ordered through mail order/home delivery after the first three fills at the local pharmacy. On the fourth fill at the local pharmacy, the drug will be denied, and you will be charged full price. The cost you pay will not be applied to your deductible.
Step Therapy
Step Therapy rules apply to the plan, which means your doctor may need to prescribe a different covered medication for you, or to confirm you have already tried that medication in the past with unsuccessful results, before certain drugs will be approved for coverage.
Prior Authorization
Prior Authorization rules also apply to the plan, which means you must receive approval for certain medications. Your doctor would need to request approval from Express Scripts for these medications by providing specific answers about your medical diagnosis and other required information.
Injectable Drugs in Doctor’s Office
For certain injectable medications for which the doctor places an individual order for you to have injected in their office, the medication must be ordered through Express Scripts (or Accredo for specialty medications) instead of through Cigna’s pharmacy in order to be covered. If you will be receiving an injectable medication for which your doctor has to order for you to be administered in his/her office, contact Express Scripts or Cigna to ask if this is a medication that needs to be filled through Express Scripts. If your doctor has already requested the medication through Cigna and you receive a denial stating the medication is not covered, contact Express Scripts to ask if the medication is covered if ordered through them instead.
Gene Therapy Drugs
Starting January 1, 2024, gene therapy drugs must be ordered and processed through Cigna’s pharmacy as a medical claim instead of through Express Scripts’ pharmacy as a prescription claim in order to be covered.
Price a Medication
If you are already enrolled in the Maritz medical plan, to see your estimated out-of-pocket cost for the current year, or to determine if your medications are subject to mail order requirements, step therapy rules, or require prior authorization, go to www.express-scripts.com, log in, and select the Manage Prescriptions, then Price a Medication link.
To see your estimated costs for the next calendar year, or if you are not currently enrolled in the medical plan and want to look up your medications, visit the Express Scripts open enrollment site at www.express-scripts.com/Maritz. This site will be open throughout the calendar year so if you are a new employee, you can access the site to look up your medications prior to enrolling, too.
Save With Your HSA
Why not lower your costs even more by paying for your prescriptions with pre-tax dollars from your HSA? Estimate the amount you think you will be paying out of your pocket for prescriptions during the year, and also take into consideration that Maritz will be contributing to this account each quarter. If your estimate shows your costs will be higher than the amount Maritz contributes, make an election to contribute that additional amount into your HSA. As you get your prescriptions filled, simply show your HSA debit card at the pharmacy to pay for your medications, or use the debit card when you place your mail order with Express Scripts Home Delivery. By paying for these expenses with pre-tax dollars, you can save approximately 20 – 40%, depending on your tax bracket. Refer to the Health Savings Account page of this website for additional details.