Prescription Drug Plan

Prescription Drug Plan  

OVERVIEW

The Sandia Total Health Prescription Plan offers reliable coverage for members enrolled in the Sandia Total Health plans. Members enrolled in the Sandia Total Health plan administered by BCBSNM and UHC are eligible for the Express Scripts Prescription Drug Program. Members enrolled in the Sandia Total Health plan administered by Kaiser will use the Kaiser pharmacy for prescription drug services.
 

Sandia has partnered with Express Scripts (BCBSNM or UHC members) for a program called "Smart90". Under Smart90 retail or mail order program, members must fill their 90-day prescriptions at a Walgreens or through mail order.

 

 

In-Network*

Out-of-Network
Prescription Drugs Retail (Maximum 30-day supply)
Generic

You pay 20%
$5/$10 min/max copay

You pay 50%
Brand-Name Preferred

You pay 30%
$25/$40 min/max copay

You pay 50%
Brand-Name
Non-Preferred

You pay 40%
$40/$60 min/max copay

You pay 50%
Prescription Drugs Mail Order (Maximum 90-day supply)
Generic

You pay 20%
$10/$20 min/max copay

n/a
Brand-Name Preferred

You pay 30%
$50/$80 min/max copay

n/a
Brand-Name
Non-Preferred

You pay 40%
$80/$120 min/max copay

n/a
  There is an annual out-of-pocket maximum of $1,500 per person for in-network prescription drugs. There is no out-of-pocket maximum for out-of-network prescription drugs.
*There is no difference between the prescription drug benefits associated with the Sandia HPN and the in-network benefits.
Contact Us

Express Scripts Customer Service

 Phone
1-877-817-1440
1-800-759-1089 (TTY)
 Hours
24 hours/7 days a week
 Website
To learn more about Express Scripts, you may register online at www.express-scripts.com.

Select "For Members" and follow instructions to register.

 

Kaiser Member Services Call Center

 Phone
1-800-464-4000
 Hours
M-F 7a-7p, Sat-Sun 7a-3p
 Website
www.kponline.org

Eligibility

Members enrolled in the Sandia Total Health plan administered by BCBSNM and UHC are eligible for the Express Scripts Prescription Drug Program. Members enrolled in the Sandia Total Health plan administered by Kaiser will use the Kaiser pharmacy for prescription drug services.

 

Plan members who have primary prescription drug coverage under another group health care plan are not eligible to use the Mail-Order Program or to purchase drugs from retail network pharmacies at the copayment level.

Prescription Drug Guidelines

  • In order to receive coverage for specialty medications, BCBSNM and UHC members must purchase these drugs through the Express Scripts Specialty Pharmacy–Accredo. These drugs are delivered via mail order through Accredo. All specialty prescriptions will be limited to a 30 day supply and will be subject to the retail coinsurance/copay structure (e.g., 30% coinsurance with a $25 minimum copay and $40 maximum copay for a preferred brand drug).
  • You must show your Express Scripts or Kaiser identification card at all retail network pharmacies. If you do not show your Express Scripts or Kaiser identification card upon purchase to identify you as a Sandia participant, you will not be eligible for any reimbursement.
  • Maximum of 30-day supply at retail network and out-of-network retail pharmacies.
  • Reimbursement for a paper claim submitted for purchases at in-network pharmacies will not be allowed (except for coordination of benefits).
  • Prescription drug copayments and/or coinsurance do not apply to your annual deductible or medical out-of-pocket limit/maximum.
  • If the actual cost of the prescription through the mail or at a retail network pharmacy is less than the copayment, you will only pay the actual cost.
  • Under the Express Scripts Prescription program, unless your physician specifies that the prescription be dispensed as written, prescriptions will be filled with the least expensive acceptable generic equivalent when available and permissible by law.
  • Under the UHC and BCBSNM program, you must ask for a 90-day prescription with refills in 90-day increments.
  • Certain prescriptions will only be dispensed with an appropriate medical diagnosis through the prior authorization process. In addition, some drugs may be subject to step therapy protocol.