Prescription Drug Benefit Frequently Asked Questions

• Are there co-payments and/or out-of-pocket maximums?

  The amount you pay is based upon your level of coverage and type of medication. Generic medications provide for the lowest cost to you and the Plan.

• Are all medications covered by the Plan?

  The Plan participates in Express Scripts' National Preferred Formulary. The formulary is a broad list of preferred medications used by Express Scripts clients nationwide and is subject to change from time to time. If your medication is removed from Express Scripts' formulary, you will be notified in advance and inform you of alternative drugs available to you in the same therapeutic class. Medications not on the National Preferred Formulary are not covered by the Plan. The Plan also excludes certain types of medications, however, therapeutic alternatives within the same medication class are covered under the Plan.

• What if my doctor prescribes a medication not covered by the Plan?

  The Plan provides for a Preferred Drug Step Therapy Program that identifies generic or brand medications in certain drug classes and recommends FDA-approved lower-cost generic options to the brand-name medication. If your doctor prescribes a non-preferred brand, you may need to try a generic or preferred brand for the Plan to cover the medication. In certain cases, if your doctor believes you cannot switch medications, they can request a coverage review by contacting Express Scripts.

• What if I use a non-participating pharmacy?

  If you use a non-participating pharmacy, you are required to pay the full cost of the drug at the retail pharmacy. You may then submit a claim to Express Scripts. Reimbursement is based on the discounted amount Express Scripts would have paid to a participating pharmacy for that drug.

• Are there refill quantity limits at a retail pharmacy for long-term medications?

  Yes, there are quantity limits. A Long-Term Medication is a medication that must be taken on a regular basis to treat a chronic health condition. If you use a participating retail pharmacy to fill your Long-Term Medications, the Plan will pay benefits for the initial 30-day prescription and 2 refills (total of 3). On your 4th fill, you are required to receive a 90-day supply through the Home Delivery Program or a Walgreen's retail pharmacy.

• Is prior authorization required for specialty medications?

  In some cases, specialty medications require certain conditions to be met before the drug can be dispensed. If your doctor prescribes a special medication, they may be required to provide information on your diagnosis, other health conditions, specific test results and other medications you are taking before the medication is approved for dispensing.