Pharmacy Coverage (Mainland)
Pharmacy coverage is provided by Express Scripts and is included with each medical plan. Your Aetna ID card includes both medical and pharmacy coverage information.
You may use all the major retail pharmacies, like CVS, Walgreens and Target. For long-term maintenance medications, you can use Express Scripts’ home delivery program, for convenience and cost savings.
Sign in at https://www.express-scripts.com/wspusa or call 844-823-5295 to set up home delivery.
Use this interactive side-by-side plan comparison to understand key differences between the plans.
| Aetna Choice POS II Basic HDHP | Aetna Choice POS II Enhanced HDHP | Aetna Choice POS II Plan | Open Access Aetna Select Plan (closed to new enrollees) | ||
|---|---|---|---|---|---|
| Retail (30-day supply): What you pay (in-network/out-of-network) + | |||||
| Generic | 20%1 ($10 max)/ Not covered | 20%1 ($10 max)/ Not covered | $10 copay/ Not covered | $10 copay/ N/A | |
| Preferred Brand | 20%1 ($40 max)/ Not covered | 20%1 ($40 max)/ Not covered | 20% ($30 min; $40 max)/ Not covered | 20% ($30 min; $40 max)/ N/A | |
| Nonpreferred Brand | 20%1 ($80 max)/ Not covered | 20%1 ($80 max)/ Not covered | 20% ($60 min; $80 max)/ Not covered | 20% ($60 min; $80 max)/ N/A | |
| Specialty2 | 20%1 ($150 max)/ Not covered | 20%1 ($150 max)/ Not covered | 20% ($100 min; $150 max)/ Not covered | 20% ($100 min; $150 max)/ N/A/ | |
| Mail Order (90-day supply): What you pay (in-network/out-of-network) + | |||||
| Generic | 20%1 ($20 max)/ Not covered | 20%1 ($20 max)/ Not covered | $20 copay/ Not covered | $20 copay/ N/A | |
| Preferred Brand | 20%1 ($80 max)/ Not covered | 20%1 ($80 max)/ Not covered | 20% ($60 min; $80 max)/ Not covered | 20% ($60 min; $80 max)/ N/A | |
| Nonpreferred Brand | 20%1 ($160 max)/ Not covered | 20%1 ($160 max)/ Not covered | 20% ($120 min; $160 max)/ Not covered | 20% ($120 min; $160 max)/ N/A | |
| Specialty2 | N/A / Not Covered | N/A / Not Covered | N/A / Not Covered | N/A / N/A | |
1 After deductible.
2 Specialty drugs must be obtained through Accredo Specialty Pharmacy. For 31-60 day supply, any applicable minimums and maximums will be two times then30-day cost share ($200 min; $300 max). For 61-90 day supply, minimums and maximums will be three times the 30-day cost share ($300 min; $450 max). Note: Your Prescription Drug List (PDL) is available on www.express-scripts.com/wspusa.
Express Scripts Programs
To help ensure the safe, appropriate and cost-effective use of medications, Express Scripts offers a number of pharmacy programs to help you receive the medication that you need:
Exclusive Specialty Pharmacy
Certain prescriptions are considered specialty medicine because they need special storage and handling, and must be delivered quickly. In addition, a nurse or pharmacist should monitor you during your treatment. If you take a specialty medication, you must have that prescription filled by Express Scripts’s Accredo Specialty Pharmacy.
You will be allowed one specialty prescription fill at an outside pharmacy before it becomes mandatory that you use Accredo Specialty Pharmacy. Accredo Specialty Pharmacy offers you:
- Free delivery that is reliable, secure and sent anywhere you choose
- Extra help when you need it — like injection training and side-effect monitoring
- Proactive outreach to confirm your refills
Mail Order for Maintenance Medications
If you require maintenance medications for a chronic condition such as allergies, high blood pressure, or diabetes, use mail order. You can purchase up to a 90-day supply and benefit from greater savings, privacy, convenience (with home delivery) and peace of mind. Log on to your member website to access this resource.
Smart90 Feature for Maintenance Medications
The Smart90 program, offered by Express Scripts, makes getting your maintenance medications easier and less costly for you.
If you are prescribed a 90-day maintenance medication, you have the option to fill your prescription at a local CVS or Walgreens pharmacy. You will be subject to the home delivery copay/coinsurance, which means you get a 90-day supply for the cost of a 60-day supply. This means more savings for you.
Formulary Drugs
Formulary drugs are brand-name medications that are favored by a prescription plan based on drug effectiveness and cost. Express Scripts maintains its own formulary list, which it updates periodically.
You can review Express Scripts’s formulary at https://www.express-scripts.com/wspusa. If a medication you are taking is excluded from the formulary list, you can ask your doctor for a new prescription for a similar medication that is on the list. Some nonformulary brand-name drugs are covered but at a higher cost to you.
Prior Authorization
Express Scripts pharmacists regularly review the most current research on newly approved medicines and existing medicines and consult with independent, licensed doctors and pharmacists to determine which medicines have been proven to be effective. Based on this review, Express Scripts determines that certain drugs require a Prior Authorization before coverage is allowed.
During the Prior Authorization process, Express Scripts will obtain information from your doctor to evaluate the prescription and decide whether it qualifies for coverage under your plan. If you are filling a new prescription that requires Prior Authorization, your pharmacist will contact your physician and request that he or she call the Express Scripts Prior Authorization for a determination.
Step Therapy
Step Therapy helps ensure you get safe and effective medicine for your condition at the lowest possible cost. Medicines are grouped in “steps.”
- First-line medicines: These are the first step and are typically generic and lower-cost brand-name medicines. They are proven to be safe and effective, as well as affordable. In most cases, they provide the same health benefit as more expensive medicines, but at a lower cost.
- Second-line medicines: These are the second and third steps and are typically brand-name medicines. They are best suited for the few patients who don’t respond to first-line medicines. They’re also the most expensive options.
If your doctor gives you a prescription that’s not on the first-line list, your pharmacist will explain that Step Therapy requires you to try a first-line medicine before a second-line medicine is covered. Since only your doctor can change your current prescription, either you or your pharmacist will need to speak with your doctor to request a first-line medicine that’s covered by your plan. If you need your prescription right away, you may ask your pharmacist to fill a small supply until you can consult your doctor.
Pharmacy Coverage (Hawaii)
Your pharmacy coverage is included with each medical plan and is provided through either HMSA PPO or Kaiser Permanente HMO, depending on the plan you choose. To receive the pharmacy benefits listed below, be sure to go to an in-network pharmacy.
Pharmacy Coverage Details
Use this interactive side-by-side plan comparison to understand key differences between the plans.
| HMSA PPO | Kaiser Permanente HMO | |
|---|---|---|
| Retail (30-day supply) (in-network/out-of-network) + | ||
| Tier 1 (Mostly Generic) | $7 copay/ $7 copay; 20% | $3 copay for maintenance; $10 copay for other generics/ N/A |
| Tier 2 (Mostly Preferred Brand) | $30 copay/ $30 copay; 20% | $45 copay/ N/A |
| Tier 3 (Mostly Nonpreferred Brand) | $75 copay/ $75 copay; 20% | $45 copay/ N/A |
| Specialty | $100 copay (Preferred); $200 copay (Nonpreferred)/ Not covered | $200 copay/ N/A |
| Mail Order (90-day supply) (in-network/out-of-network) + | ||
| Tier 1 (Mostly Generic) | $11 copay/ Not covered | $6 copay for maintenance; $20 copay for other generics/ N/A |
| Tier 2 (Mostly Preferred Brand) | $65 copay/ Not covered | $90 copay/ N/A |
| Tier 3 (Mostly Nonpreferred Brand) | $200 copay/ Not covered | $90 copay/ N/A |
| Specialty | Not covered / Not covered | N/A / N/A |
Formulary drugs are brand-name medications that are favored by a prescription plan based on drug effectiveness and cost. The HMSA PPO Drug Formulary List is available for download from the Help Center on the HMSA PPO website: https://hmsa.com/help-center/your-hmsa-drug-formulary-list/. Your plan uses the Essential Formulary.
The Kaiser Permanente HMO Drug Formulary List is available for download. Your plan uses the Kaiser Permanente HMO Hawaii Marketplace Drug Formulary.
Eligibility and How to Enroll
To learn more about benefits eligibility and how to enroll in your benefits, visit Eligibility and How to Enroll.
Employee Premiums
Your pharmacy premiums are covered under your medical premiums. To learn more, visit Employee Contributions.