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Texas Health
Insurance Pool
1-888-398-3927
TDD 1-800-735-2989
 
www.txhealthpool.org
texashealthpool@bcbstx.com

   
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                  About the Pool


 

Health Pool  Pharmacy Program


Important Notices:

Prescription Drug Benefit Summary:

  • No Calendar Year Benefit Limit

  • $200 Annual Deductible for Plans I, II & III

  • $500 Annual Deductible for Plan IV

  • $1,450 Annual Deductible for High Deductible Health Plan/
    HSA-Qualified Plan V

 I.  Retail Pharmacy Copays (up to a 30-day supply)

  • Generics......................$10

  • Formulary Brands.........$25 (plus cost difference if generic available)

  • Non-Formulary Brands..$40 or 50% of the cost of the drug, whichever is greater
                                       (plus cost difference if generic available)

 II.  Medco Mail Order Pharmacy Copays (up to 90-day supply)

  • Generics...................... $25 

  • Formulary Brands......... $60 (plus cost difference if generic available)

  • Non-Formulary Brands...$100 or 50% of the cost of the drug, whichever is greater
                                        (plus the cost difference if generic is available)

 III.  Specialty Medication Medication Copays:  $100  (30-day supply)

  • Specialty Medications are prescription drugs that cost $500 or more per dose, or $6,000 or more per year,* and have one or more of the following characteristics:

  • Complex therapy for complex disease

  • Specialized patient training and coordination of care (services, supplies, or devices) required prior to therapy initiation and/or during therapy

  • Unique patient compliance and safety monitoring requirements

  • Unique requirements for handling, shipping, and storage

  • Potential for significant waste due to the high cost of the drug  

*Exceptions to the price threshold may exist based on certain characteristics of the drug or therapy which will still require the drug to be classified as a specialty drug. In addition, a follow-on biologic or generic product will be considered a specialty drug if the innovator drug is a specialty drug.

Specialty Drug List link:  Specialty Medications

  • Certain specialty medications are covered by the Pool only when they are provided through the Pool's pharmacy benefit, by Express-Scripts--Medco/Accredo.  These medications consist of all hemophilia factor, growth hormone medications, and medications to treat metabolic disorders.

 NOTES:

  • The outpatient prescription drug benefit is not available to a Pool enrollee who is also eligible for Medicare.

  •  $1,500 annual cap on copayments for HSA-Qualified Plan V.

 

Express Scripts administers the Pool's outpatient prescription drug benefit.  If you have any questions
 about your prescriptions, please call Express Scripts customer service at:
 1-800-290-1708.  

IMPORTANT LINKS:

  Manage Your Drug Benefit at www.express-scripts.com
Tip: When registering, enter only 
your 9-digit numeric ID# in the 
Member Number field


Prescription Drug Benefit Handbook
--  Regular Plans

Prescription Drug Benefit Handbook -- HSAQ Plan

Pool Drug Formulary

 Pharmacy Chain Network

  Retail Prescription Claim Form

 Specialty Medications List

Prior Authorization Drug List

 
Contact Express Scripts by telephone at
1-800-290-1708

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