PHARMACY BENEFITS – PELICAN HRA1000 & MAGNOLIA PLANS

These plans use the Express Scripts formulary. The formulary is reviewed regularly to reassess drug tiers based on the current prescription drug market. Members will continue to pay a portion of the cost of their prescriptions in the form of a co-pay or coinsurance. The amount members pay toward their prescription depends on whether or not they receive a generic, preferred brand, non-preferred brand or specialty drug.

Tier

Member Co-Pay*

Generic

50% up to $30

Preferred

50% up to $55

Non-Preferred

65% up to $80

Specialty

50% up to $80

Once you pay $1,500:

Generic

$0

Preferred

$20

Non-Preferred

$40

Specialty

$40

Click on the links below for more information on the pharmacy benefits through Express Scripts.

Active Employee/Non-Medicare Retiree Formulary
Medicare Retiree Formulary
Multi-source Brand Drugs

PHARMACY BENEFITS – PELICAN HSA775

Blue Cross and Blue Shield of Louisiana works in partnership with Express Scripts® to administer your prescription formulary drug program for the Pelican HSA775. Prescriptions are subject to the plan deductible with the exception of maintenance medications.

Tier

Member Co-Pay*

Generic

$10

Preferred

$25

Non-Preferred

$50

Specialty

$50

*Subject to deductible and applicable co-payment. Maintenance drugs are not subject to the deductible.

Click on the links below for more information on the pharmacy benefits through Express Scripts.

Express Scripts 2022
Maintenance/Preventative Drug List
Blue Selections – Rx Member Guide

PHARMACY BENEFITS – VANTAGE HEALTH PLAN

The Vantage Medical Home HMO prescription drug benefit has five copayment levels. There is no prescription drug deductible. You may view the Vantage Rx Formulary at: www.vantagehealthplan.com/OGBCommercial/Documents

Tier

Member Co-Pay*

Tier 1 Preferred Generics

0 AHN/$10

Tier 2 Non-Preferred Generics

$40

Tier 3 Preferred Brand

$65

Tier 4 Non-Preferred Brand

$100

Tier 5 Specialty

$150

 

PHARMACY RESOURCES

Express Scripts

www.express-scripts.com

1-877-417-2949

24 Hours, Seven Days a Week

Active Employee & Non-Medicare Retiree Formulary

Express Scripts Medicare

http://www.express-scripts

1-866-781-7533

6:00 AM – 11:00 PM CT

Seven Days a Week

Medicare Retiree Formulary

Express Scripts (Pelican HSA775)

http://www.express-scripts

1-866-781-7533

Seven Days a Week

Medicare Retiree Formulary

Express Scripts Rx Checker

Vantage Health Plan Pharmacy Benefits

http://www.express-scripts

1-866-704-0109

8:00AM-8:00PM CT, Mon-Fri

Medicare Retiree Formulary