Prescription Drug Coverage
Retail and mail order prescription drug coverage is included when enrolled in a medical plan. The University prescription plan is administered by Express Scripts. Express Scripts utilizes a formulary drug listing. These lists are not all-inclusive and do not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate.For more information on the formulary visit: http://lab.express-scripts.com/about/formulary-information/. Formulary listings are maintained and controlled by a prescription benefits management company (PBM) and is subject to changes as directed by PBM.
Visit https://www.express-scripts.com and create an account to manage prescriptions, comparison shop, view claims and balances, locate a pharmacy, price a medication and more.
Elements of the Express Scripts prescription drug plan include the Advanced Utilization Management, Generics Preferred and Exclusive Home Delivery Programs.
Advanced Utilization Management Program
These programs may require additional information from a prescribing physician in order for a prescription to be covered and paid for by the University’s health plan. Failure to provide additional information may result in a prescription not being covered by the health plan.
Drug Quantity Management
Under Drug Quantity Management, Express Scripts monitors the amount of medication prescribed compared to the recommended level for a medication. For example, if medical guidelines state a medication should be taken no more than once per day and a physician prescribes it for two times per day, Express Scripts will reach out to the physician for justification regarding the higher amount prescribed. Sufficient justification will be required in order for the additional medication to be approved.
These programs may require additional information from a prescribing physician in order for a prescription to be covered and paid for by the university’s health plan.
Under Step Therapy, an individual may be required to use a therapeutically equivalent and less costly drug where available and appropriate (such as a generic prescription) prior to being able to a more costly medication.
Under Prior Authorization, Express Scripts will require pre-approval be obtained for certain medications in order for the drug to be covered by the health plan. For mediations requiring prior authorization, a physician will be required to provide documentation that the patient meets the established medical guidelines for the medication. This may include prescriptions individuals are currently receiving.
Please contact HR-Benefits at firstname.lastname@example.org if you have any questions regarding these programs.
Generics Preferred Program
The University's prescription drug plan includes a "generics preferred" program. When employees or family members need a new prescription or a refill for a brand-name drug, the pharmacist will check whether a generic drug is available instead. If a generic is available, employees are encouraged to utilize the generic option. If the employee chooses to use the brand-name instead of the generic, the employee will be charged the full cost difference between the generic and the brand-name drug. If there is no generic available, the employee will be charged the normal brand name copay.
Exclusive Home Delivery Program
The University's prescription drug plan includes an "exclusive home delivery" program. The Exclusive Home Delivery Program pertains to maintenance medications, or prescription drugs for ongoing conditions such as diabetes or high blood pressure.
Under the Exclusive Home Delivery Program, employees can fill a prescription of a maintenance medication up to 2 times at a retail pharmacy such as CVS, Wal-Mart, or Kroger. After that, the University's health plan will cover the medication only if it is ordered through the Express Scripts Mail Order Pharmacy.
Schedule II drugs and narcotics are exempted from the exclusive home delivery program. These drugs can often be dispensed only 30 days at a time. Employees can use retail or mail order for these. There is no mail order requirement. Examples: oxycodone, ritalin, dexedrine, etc.
Other drugs with manufacturer or FDA supply limits are also exempted from the exclusive home delivery program. If a doctor is only allowed to prescribe a 30 day or other limited supply, there is no mail order requirement for that drug.
Contact Express Scripts directly at 1-866-515-1442 about specific medications.