Plan Benefits
The following chart provides a summary of outpatient drug coverage administered by Express Scripts.
 
Prescription Drug Benefits for NAP and CAP Members (Administered by Express Scripts)
Prescription Drug Benefits for ROP Members (Administered by Express Scripts)
Prescription Drug Benefits for MSP Members (Administered by Express Scripts)
Retail Drug Purchases
First three 30-day fills of maintenance drugs and all 30-day fills of non-maintenance drugs:
At participating pharmacy:
  • 85% for generic
  • 75% for brand
At non-participating pharmacy:
  • 80% for generic
  • 70% for brand
You pay extra 5% coinsurance for 4th refill and beyond of maintenance drugs
Generic Incentive Provision applies*
  • 60% after deductible at any retail pharmacy.
After deductible, plan pays 75% of eligible expenses not covered by Medicare.
Generic Incentive Provision applies.
Express Scripts Mail-Order Pharmacy
90% for generic drugs and 80% for brand-name drugs, up to a 90-day supply.
Generic Incentive Provision applies.
100% for drugs on Express Scripts' Low-Cost Generic List
All Other Drugs: 70% after deductible for a 90-day supply.
100% for drugs on Express Scripts' Low-Cost Generic List
All Other Drugs: 80% after deductible for a 90-day supply.
Generic Incentive Provision applies.
Generic Incentive Provision
Member is responsible for paying the difference between the price of a generic drug and a brand-name drug, plus coinsurance, if purchasing a brand-name drug when a generic version is available. Please note that any generic-brand price differential you pay is a non-covered expense and, thus, does not count towards your deductible or annual out-of-pocket maximum.
Member is responsible for paying the difference between the price of a generic drug and a brand-name drug, plus coinsurance, if purchasing a brand-name drug when a generic version is available. Please note that any generic-brand price differential you pay is a non-covered expense and, thus, does not count towards your deductible or annual out-of-pocket maximum.
Member is responsible for paying the difference between the price of a generic drug and a brand-name drug, plus coinsurance, if purchasing a brand-name drug when a generic version is available. Please note that any generic-brand price differential you pay is a non-covered expense and, thus, does not count towards your annual out-of-pocket maximum.
Deductible
No deductible.
  • $200/person for retail and mail-order combined
  • No family maximum
  • $100/person for retail and mail-order combined (but separate from medical plan deductible)
  • No family maximum
Annual Out-of-Pocket Maximum
  • $500 per person, $1,000 per family.
  • Out-of-pocket maximum covers both retail drug plan and mail-order drug plan. Non-covered expenses, such as generic-brand price differentials and other penalties, are not eligible expenses and, thus, will not count toward your deductible or out-of-pocket maximum, nor will these expenses be covered by the Plan after your annual out-of-pocket maximum is met.
  • For retail and mail-order combined (but separate from medical plan out-of-pocket maximum):
  • $1,500/person
  • No more than $3,000/family
  • None
Lifetime Maximum
None
None
Lifetime limit of $10,000/person; up to $1,000 restored each year (does not apply to drugs purchased before 2004)
Infertility, Sexual Dysfunction and Memory Enhancement Drugs
  • You pay 50% for both retail and mail-order plans, unless medically necessary.
  • Medically necessary drugs are covered at standard reimbursement rates.
  • Generic Incentive Provision applies.
Plan pays 50% after deductible
  • Covered only to treat serious medical conditions.
Express Scripts has negotiated rates with many retail pharmacies. Benefits for prescription drugs purchased at these pharmacies are paid based on these negotiated rates. The pharmacies that Express Scripts has negotiated with are called "participating" pharmacies. To receive the greatest benefit on retail prescriptions, participating pharmacies should be used. A directory of participating pharmacies can be obtained by calling Express Scripts Member Services at 800-718-6590 or by visiting Express Scripts' website at www.express-scripts.com. You also can use Express Scripts' mail-order program for your maintenance drugs.
Manufacturer rebates are earned upon participant purchase of certain prescription drugs. The value of these rebates is based on the contract that Pacific Gas and Electric Company, as Plan sponsor, has with Express Scripts. These rebates are received from Express Scripts approximately six months after the purchase of a drug and are deposited back into the trust holding the plan assets for retirees or employees on long-term disability or back to the company for active employees. The cost of the Plan is reduced by the value of the rebates.