Express Scripts
MTM partners with Express Scripts (ESI) to administer prescription benefits under both EPO medical plans and the HDHP with HSA plan. While all plans share the same pharmacy network, programs, and features (Smart90, Accredo, insulin caps, etc.), the way you pay for prescriptions differs depending on your plan.
Pharmacy Benefits Overview (UMR Plans)
Preventive medications
Some preventive drugs may be fully covered with a $0 copay depending on the IRS preventive drug list and ACA requirements.
Retail vs. Mail Order
- Retail fills are limited to 30 days.
- Mail order & Smart 90 through Walgreens fills up to 90 days.
- Maintenance medications must transition to Mail order or Smart90 after two retail fills.
Brand vs. Generic Rule
If a generic is available and you choose a brand:
- You pay the brand copay/coinsurance, plus
- The difference in cost between brand and generic. This penalty does not count toward your deductible or out‑of‑pocket maximum.
What’s Not Covered
- OTC medications (except insulin and certain epinephrine kits)
- Cosmetic drugs
- Infertility medications
- Drugs for baldness
- Take‑home drugs dispensed by a medical facility
Only the Select EPO plan covers weight loss medications with:
- BMI of 35+ or 27-34 with 2 weight-related comorbidities, and
- Engagement in Omada App
How Your Costs Work: EPO vs. HDHP
EPO Pharmacy Coverage
The EPO plans use simple copays—no deductible applies to prescription drugs.
Retail Pharmacy (30‑day supply)
- Generic: $20 copay
- Preferred Brand: $40 copay
- Non‑Preferred Brand: $80 copay
Mail Order & Smart 90 through Walgreens (90‑day supply)
- Generic: $50 copay
- Preferred Brand: $100 copay
- Non‑Preferred Brand: $200 copay
HDHP with HSA Pharmacy Coverage
Under the HDHP, medical and pharmacy expenses share one deductible. You pay the full cost of non‑preventive medications until you meet your deductible.
After the deductible is met, your cost is:
- Generic: 30% after deductible
- Preferred Brand: 30% after deductible
- Non‑Preferred Brand: 30% after deductible
Mail Order & Smart 90 through Walgreens (90‑day supply)
- Generic: 30% after deductible
- Preferred Brand: 30% after deductible
- Non‑Preferred Brand: 30% after deductible
Program Features
Smart90 – Maintenance Medication Program
To keep costs low and ensure you receive a 90-day supply of ongoing medications, MTM requires maintenance prescriptions be filled through:
- Express Scripts Mail Order, or
- Walgreens (Smart90 retail partner)
You may fill your maintenance medication twice at any participating pharmacy. After two fills, you must switch to Smart90 or pay the full cost, which does not count toward your out-of-pocket maximum.
Specialty Medications – Accredo® Required
All specialty prescriptions must be filled through Accredo, Express Scripts’ specialty pharmacy.
Specialty medications often require:
- Temperature controls
- Special delivery
- Clinical monitoring
Accredo supports members through dedicated specialty teams and manufacturer copay assistance (note: assistance does not count toward your deductible or out-of-pocket maximum).
Diabetes Care Value & Insulin Cost Protection
MTM participates in Express Scripts’ Diabetes Care Value (DCV) program, providing:
- Free digital glucose monitoring device
- Coaching from a pharmacist
- Support with nutrition and diabetes management
Plus, preferred insulin products cost no more than $25 for a 30‑day supply at any in‑network pharmacy or Express Scripts Mail Order.
Need Help?
For pharmacy questions, contact Express Scripts: 800‑753‑2851 or log into your Express Scripts account online.
