Prescription Coverage - PPO Blue

Effective January 1, 2016, Target pharmacy will be in the Express Scripts pharmacy network.

The Pharmacy Benefit Manager for Highmark Blue Shield is Express Scripts.

Note: When an individual's combined out-of-pocket expense for prescription drugs reaches $1,000, their prescription drugs will be covered at 100% for the remainder of the calendar year.

Prescription Coverage Chart
Deductible None None
Retail 31 day supply
Mail Order 90 day supply
Member Pays:
50% Coinsurance for Generic/Brand Formulary

70% Coinsurance for Non-Formulary
Member Pays:
20% Coinsurance for Generic/Brand Formulary

70% Coinsurance for Brand Non-Formulary
Specialty Medications (Walgreen's Speciality Pharmacy Only) Member pays:

50% Coinsurance with a maximum copayment of $50 per prescription for Specialty Rx covered on the formulary

70% Coinsurance with a maximum copayment of $100 per prescription for Specialty Rx not covered on the formulary
Not covered
Formulary Three tier
Generic Substitution When you purchase a brand drug that has a generic equivalent you will be responsible for the brand drug copayment plus the difference in cost between the brand and generic drugs, unless medically necessary
Out-of-Pocket Maximum $1,000 per member
Claim Submission Pharmacy Files at Point-of-Sale
Non-Network Pharmacy Not Covered
Contraceptives (oral and injectable) Covered
Fertility Agents Not Covered
Fluoride Products Covered
Weight Loss Drugs Covered
Insulin and Diabetic Supplies Covered
Tobacco Deterrents
(prescription and over the counter)

Gum, inhalers, patches, nasal spray and oral drugs specifically targeted at tobacco cessation
Exclusive Pharmacy Provider-Walgreens
30 day supply
Selected high cost prescription drugs are covered only when they are dispensed through an exclusive pharmacy provider.
Quantity Level Limits on select prescription drugs The quantity dispensed under your plan per new or refill prescription may be limited per recommended guidelines.
Managed Rx Coverage on certain drug therapies Certain drug therapies may be monitored for appropriate usage and subject to case evaluation if recommended guidelines are exceeded.
Managed Prior Authorizations Select drugs may need prior authorization.

Retail Prescriptions

  • Drugs that are purchased at your local participating pharmacy
  • Maximum supply available is 31 days
  • You pay 50% of the cost at the counter
  • Medication that is not on the formulary will require you to pay 70% of the cost

Generally, the retail method is used for short-term prescriptions, such as an antibiotic. While maintenance drugs can be purchased on a retail basis, the maintenance prescription drug plan is more cost effective.  

Mail Order Maintenance Prescriptions

  • Drugs that are prescribed for the long-term treatment of a condition
  • Maximum supply available is 90 days
  • You pay 20% of the cost
  • Medication that is not on the formulary will require you to pay 70% of the cost

Maintenance drugs are available from Express Scripts by Mail and from the University Health Services Pharmacy. You can order refills online and by phone.

Drugs purchased through Express Scripts will be delivered to your home address. Drugs purchased from University Health Services Pharmacy can be delivered by campus mail at no cost or by U.S. Mail to your home for a $3.00 fee. 

Specialty Medications

Specialty medications are typically self-administered indictables, biological agents, biotechnology medications and other prescriptions that are not available at most pharmacies.

  • Walgreens Specialty Pharmacy is the exclusive provider for certain specialty medications
  • Dispensed in one-month supplies
  • Maximum cost $50/month for formulary drugs and $100/month for non-formulary drugs
  • Walgreens Specialty Medications Formulary

You can access more details about your coverage and the Express Scripts formulary through Highmark or through Express Scripts with an account registration and log-in.

If you have any questions, contact Highmark Blue Shield at 1-800-914-4384. This is a dedicated line for Penn State faculty and staff.

Additional Resources