What you need to know
Sandia’s Total Health medical plans include prescription drug coverage.
There is no annual deductible for prescription drug coverage – meaning, your Sandia Total Health plan coverage begins right away.
And, you can save money by making smart choices about your prescription medications:
- You pay the lowest cost for generic drugs; you pay more for brand-name preferred and non-preferred drugs.
- You also save money when you use a network pharmacy or provider for your prescriptions.
- And, you save money when you use the mail-order service for your 90- to 100-day refills.
Use the links below to learn more about the prescription drug coverage for your medical plan (BCBSNM, UHC, or Kaiser).
BCBSNM and UHC Prescription Coverage
If you are enrolled in one of these medical plans, Express Scripts administers your prescription drug coverage.
You can use a retail pharmacy or the mail-order service to fill your prescription depending on the supply you need.
If your prescription is for 30 to 90 days, go to a retail pharmacy.
For supplies of 90 days or more, you must use the Express Scripts Smart90 option – it’s convenient and saves you money.
With Smart90, you can receive a 90-day supply at a lower cost than a 30-day supply filled at a retail pharmacy. There are two options to receive medications:
- Express Scripts pharmacy home delivery
- A participating Walgreens pharmacy
To sign up, go to www.express-scripts.com.
The list of covered medications is called the formulary.
To check coverage for your medication, start with the Express Scripts preferred drug list.
If you don’t see your medication, call Express Scripts at 877-817-1440.
Express Scripts offers an extended payment option for long-term medications. The extended payment program (EPP) spreads your prescription payments over three installments.
Kaiser Permanente Prescription Coverage
You will save money (and time) when you fill your prescriptions through Kaiser Permanente’s pharmacies and providers.
You can use the Kaiser Permanente pharmacy or mail-order service to fill your prescription depending on the supply needed.
You can fill short-term prescriptions – up to a 30-day supply – at Kaiser Permanente pharmacies.
The mail-order service offers a convenient and cost-effective delivery option for long-term and maintenance prescriptions – up to a 100-day supply.
You can go online to find a Kaiser pharmacy, sign up for mail service, or refill your prescriptions.
The list of covered medications is called the formulary.
To check coverage for your medication, visit the Kaiser Permanente website or call 800-663-1771.
Coverage Highlights
While Sandia Total Health medical plans are administered by different
vendors with different formulary lists, member cost sharing is the
same.
| RETAIL PHARMACY: MAXIMUM 30-DAY SUPPLY – NETWORK | ||
|---|---|---|
| Category | In-Network | Out-of-Network |
| Generic |
You pay 20%
$5/$10 min/max copay |
You pay 50% |
| Brand-name preferred |
You pay 30%
$30/$45 min/max copay |
You pay 50% |
| Brand-name non-preferred |
You pay 40%
$50/$75 min/max copay |
You pay 50% |
|
SMART90 RETAIL/MAIL ORDER: MAXIMUM 90-DAY SUPPLY
(100-DAY SUPPLY FOR KAISER MAIL ORDER) |
||
|---|---|---|
| Category | In-Network | Out-of-Network |
| Generic |
You pay 20%
$12.50/$25 min/max copay |
N/A |
| Brand-name preferred |
You pay 30%
$75/$112.50 min/max copay |
N/A |
| Brand-name non-preferred |
You pay 40%
$125/$187.50 min/max copay |
N/A |
Note: There is an annual out-of-pocket maximum of $1,500 per person (or
$5,950 per family) for in-network prescription drugs. There is not an
out-of-pocket maximum for out-of-network prescription drugs or for
Smart90 prescription drugs purchased outside of the program.
Monthly premiums
Prescription drug coverage is included in your monthly medical plan premium. The premiums are posted in the Sandia My Way Open Enrollment brochure.
Contacts and Resources
Express Scripts (BCBSNM and UHC Participants)
877-817-1440
https://www.express-scripts.com/
Kaiser Permanente Participants
800-663-1771
healthy.kaiserpermanente.org
Quick Tip
Save with generic drugs
Talk with your doctor to see if a generic drug is right for you. The Food and Drug Administration (FDA) requires generic drugs to have the same chemical composition, strength, and dosage as the brand-name drug, but they typically cost 30% to 70% less.