Prescription Drugs
Express Scripts, Inc. is the pharmacy benefit manager for members of the WELS VEBA Group Health Care Plan. Express Scripts customer service is available at: 1-800-818-6634. Members can also manage their prescription drug coverage on the Express Scripts website at: www.express-scripts.com.
Prescription drug coverage identification and customer service contact information is included on the WELS VEBA ID card for medical services.
Retail Pharmacy
A WELS VEBA member may use his/her ID card at an Express Scripts network retail pharmacy to purchase up to a 30-day supply of covered prescription drugs. The member will be responsible to pay the applicable co-pay for the prescription drug at the pharmacy. If you utilized a non-network provider or you did not have your ID card at the time of the prescription purchase, complete an Express Scripts prescription drug reimbursement form and mail it along with the itemized receipt to the address on the form to obtain a reimbursement of the charges paid in excess of the applicable co-pay.
Mail Service Pharmacy
A WELS VEBA member may use the Express Scripts Mail Service Pharmacy when the member’s physician writes a prescription which exceeds a 30-day supply. The member may obtain up to a 90-day supply of the covered prescription drug by Mail Service Pharmacy.
To begin utilizing the Express Scripts Mail Service Pharmacy, a member should submit the Express Scripts mail-order form to the Mail Service Pharmacy. The member would pay the applicable co-pay for each covered prescription drug to the Mail Service Pharmacy. The member does not need to submit a claim to WELS VEBA.
Member Co-pay Amounts
The table below shows member co-pay amounts for covered prescription drugs obtained at a Retail Pharmacy or Mail Service Pharmacy by members enrolled in WELS VEBA Plans 1, 2 and 4:
| Drug Status | Retail Co-Pay (30-day supply) | Mail Co-Pay (90-day supply) |
|---|---|---|
| Generic | $10 | $25 |
| Formulary (Preferred) brand name drugs | $30 | $75 |
| Non-Formulary (Non-preferred) & other brands | $60 | $150 |
Important! Members enrolled in the HSA-compliant WELS VEBA Plan 3 ($3000 individual/$6000 family deductibles) are required to pay the full discounted cost of their prescription drugs until their deductible has been met. WELS VEBA pays 100% of the covered prescription drug expenses for Plan 3 members for the remainder of the plan year after the applicable Plan 3 deductible is met.
Prescription Drug Out-of-Pocket Maximums
An annual maximum limit on member out-of-pocket costs for covered prescription drugs is applicable to all WELS VEBA plan options. This maximum out-of-pocket limit for prescription drugs is separate from the maximum out-of-pocket limit for medical services. Once a member’s out-of-pocket co-pay amounts for prescription drugs attain the applicable annual limit, covered prescription drug expenses will be paid at 100% by WELS VEBA for the remainder of that plan year. Please consult the chart below to identify the out-of-pocket limits applicable to each WELS VEBA plan option.
| WELS VEBA Plan Option | Prescription Drug Out-of-Pocket Maximum for an Individual | Prescription Drug Out-of-Pocket Maximum for a Family |
|---|---|---|
| Plan 1 | $1,000 | $2,000 |
| Plan 2 | $1,000 | $2,000 |
| Plan 3 | Applied to Medical Deductible; then Plan pays 100% | Applied to Medical Deductible; then Plan pays 100% |
| Plan 4 | $500 | $1,000 |
Clinical Prior Authorization Program
Certain prescriptions require this type of authorization or approval before they will be covered. To confirm if you need clinical approval before beginning a prescription drug regimen, call Express Scripts at 1-800-818-6634.
Specialty Pharmacy
Certain medications for treating complex health conditions must be obtained through this program to be covered by WELS VEBA. These specialty drugs are required to be filled through the Express Scripts specialty drug mail service pharmacy, Accredo, following the second fill obtained at a retail pharmacy. Members will pay the entire cost of their specialty drugs for all future refills if any pharmacy other than Accredo is used after the second fill. Please call Accredo at 1-800-803-2523 for more information about this program.
Step Care Therapy
This program encourages members to use the most appropriate prescription drugs to treat certain medical conditions. This program requires use of preferred medications prior to coverage of other medications. For additional information regarding this program, call Express Scripts at 1-800-818-6634.