How the Plan Works
Retail Pharmacy Service
The Retail Pharmacy Service, managed by Express Scripts, helps you pay for retail prescription drugs — that is, drugs that you purchase at local pharmacies. You have coverage under the Retail Pharmacy Service only if you are enrolled in a medical plan administered by Anthem Blue Cross.
When you enroll in one of the self-insured plans administered by Anthem Blue Cross, you are issued a member identification card by Express Scripts. Go to any participating pharmacy (such as CVS, Rite Aid, Walgreens, Raley's or a number of independent pharmacies), present your card identifying you as an Express Scripts member, and pay the appropriate coinsurance. You may also go to a non-participating pharmacy; however, you will be responsible for paying the entire cost of the prescription upfront and then filing a claim form for reimbursement. It is likely that a non-participating pharmacy will charge more than the pre-negotiated rates of a participating pharmacy. Reimbursement is based on the amount a participating pharmacy would have charged, minus the coinsurance amount. You may call 800-718-6590 or go to www.express-scripts.com to verify pharmacy participation.
Maintenance drugs (i.e., those you use on an ongoing basis) purchased at a participating retail pharmacy will be reimbursed for up to three 30-day supplies at 85% for generic drugs and 75% for brand-name drugs. However, for retail refills of maintenance drugs beyond 90 days, the reimbursement rate for drug purchases at participating pharmacies will be 80% for generic and 70% for brand-name drugs. For example, members will be reimbursed at 85% for an initial 30-day supply of a generic maintenance drug as well as for two 30-day generic refills at a participating retail pharmacy. If the member requests a fourth prescription of a maintenance drug at a participating retail pharmacy, the reimbursement rate will drop to 80% because the 90-day supply limit for maintenance drugs will have been exceeded. Therefore, it is suggested that members use the Express Scripts' mail-order pharmacy service for refills of maintenance drugs beyond a 90-day supply.
  • Ask your physician for two separate prescriptions: one prescription for a 30-day supply (to be filled at your local retail pharmacy) and one prescription for a 90-day supply (to be filled through Express Scripts' mail-order pharmacy).
  • Have your 30-day prescription filled immediately at your retail pharmacy. About two weeks later (after you have used up half of your 30-day supply and have decided to continue taking this particular prescription drug), submit your 90-day prescription to Express Scripts' mail-order pharmacy. This will allow a 14-day turn-around for your mail-order prescription to be delivered to your home. Express Scripts will not issue your 90-day supply if you send your order in any sooner than this because it will still be too early to fill the prescription.
When Claim Forms Are Required
You will need to pay the full cost of your prescription and file a claim form for reimbursement if you:
  • purchase drugs at a non-participating pharmacy;
  • do not present your Express Scripts identification card when purchasing drugs at a participating pharmacy; or
  • have other prescription drug coverage which pays first before Express Scripts and you want Express Scripts to pay second on any claim remainder. This is called a Coordination of Benefits or "COB" claim; see "If You Have Other Coverage" in the Health Care Participation section.
A member may obtain prescription drugs from participating pharmacies without using their membership card and then seek reimbursement from Express Scripts by submitting a claim form. However, the member's reimbursement in such cases will be limited to the cost for the drug negotiated by Express Scripts and the pharmacy. Any additional amounts charged to the member by the pharmacy will be the member's responsibility.
To obtain a claim form, call Express Scripts Member Services at 800-718-6590 or visit Express Scripts' website at www.express-scripts.com. If you are a first-time visitor to www.express-scripts.com, take a minute to register. Please remember to have your member ID number and a recent prescription number handy.