SSMC Employee Health Benefit Plan
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7. Mail Service for Maintenance Drugs. If this Plan is the primary plan according to the order of benefit
determination rules shown in Section VII - Coordination of Benefits (COB) primary, maintenance drugs
for you or your Dependents may be obtained from the EHS mail service, Express Pharmacy Services
(EPS). This service delivers the drug directly to your home. Maintenance drugs are medications that are
taken for chronic conditions. Examples of maintenance medications are drugs for the treatment of chronic
disorders such as hypertension, heart disease, thyroid disease, and diabetes. In addit ion, acute care
medications with prescriptions written for more than 21 days (one refill) may be obtained through the mail
service. EPS bills the Plan.
a. Mail Order Copayment:
Brand Name
With generic equivalent:
$ 7.00 per each prescription or refill.
With no generic equivalent:
No Copayment. Plan pays 100% of Network allowance
Generic: No Copayment. Plan pays 100% of Network allowance.
b. How to Use the Mail Service Pharmacy Program
1) When your Doctor writes a prescription for a "maintenance drug" (one taken regularly or on a
long-term basis) ask him or her to indicate the number of refills allowed.
2) For your first mail service order, complete the supplied patient profile/registration form. Enclose
the completed form in the self-addressed envelope with the original prescriptions written by your
Doctor and mail.
3) For original and refill prescriptions, complete the supplied order form. EPS will include a new
order form and envelope with each delivery.
4) Your medication will be delivered to you by first-class or UPS. You should allow 10-14 days from
the time you mail your prescription forms to EPS until delivery of your medication. However, to
ensure that you do not leave yourself without an adequate supply of medication, you will be best
protected if you order when you have a minimum of a three-week supply of your current
medication.
Express Pharmacy Services
PO Box 270
Pittsburgh, PA 15230-9913
For Refill Orders Phone Toll- free: 1-888-645-9303
7. Prescription Drug Expense Exclusions. In addition to limitations shown otherwise in the Plan, the
following drugs or Supplies are not covered under Prescription Drug Expense Benefits. See also Section V
- Plan Exclusions shown later in this MPD.
a. Non-Legend drugs/over the counter (drugs obtainable without prescription), unless otherwise noted.
b. Implantable time-released medication (i.e., Norplant).
c. Therapeutic/diagnostic devices and appliances unless otherwise noted.
d. Infertility or fertility medications unless pre-authorized.
e. Cosmetic medication including but not limited to anti-wrinkle medications, hair growth medications,
and any drugs FDA approved for Cosmetic use only.
f. Immunization agents, vaccines, allergy extracts, biologicals, and blood or plasma.
g. Nutritional supplements or products unless otherwise noted.
h. Growth hormones unless pre-authorized.
i. Experimental drugs or drugs prescribed for Experimental (non-FDA approved/unlabeled indications).
j. Extemporaneously prepared combinations of raw bulk chemical ingredients (i.e. progesterone,
testosterone, or estrogen powders) or combinations of federal legend drugs in a non-FDA approved
dosage form (i. e. capsules or suppositories made from DHEA, progesterone, testosterone or estrogen
powders).
k. Charges for the administration of any medication.
