Prior Authorization

Your prescription drug program provides coverage for some drugs only if prescribed for certain uses, durations, and/or quantities. For this reason, some prescriptions must receive prior authorization before they can be covered under your benefit. Either your pharmacist may initiate the review process or you may be asked to request that your doctor initiate the review. It may be required at times for Express Scripts to contact your doctor to get necessary information to determine coverage eligibility. Following the review process, both the member and the physician will be notified as to the results of the review process. If your prescription is found not to be covered, you will be required to pay the full price of the prescription. An appeals process is available in the case of coverage denial.

Specialty Drugs

Specialty medications must be purchased through Accredo®, the specialty pharmacy at Express Scripts, or Duke Specialty Pharmacy to be eligible for coverage under the plan, unless they are medications which are intended for an immediate need. A list of covered specialty drugs as of November 2022 is available here (this listing is subject to change). New users of some specialty drugs will need their physicians to obtain prior authorization from Express Scripts before prescribing the drugs.

What Drugs Are Covered?

• Legend drugs (federal law requires these drugs be dispensed by prescription only)
• Insulin
• Disposable insulin syringes/needles
• Blood glucose testing strips, lancets, glucometers
• Legend contraceptives; injectable contraceptives through age 50 with copay waived; over age 50 subject to applicable copayment
• Any other drug which, under the applicable state law, may only be dispensed upon the written prescription of a physician or other lawful prescriber
• Growth hormone for certain conditions -- must be precertified.
• Topical tretinoin products (such as Retin A®) through age 35; over age 35 with approval through prior authorization

What Drugs Are Not Covered?

• For compounded medications to be covered, they must satisfy certain requirements. In addition to being medically necessary, each ingredient must be studied for use in this type of preparation, and be dispensed by a participating network pharmacy. In order to be sure your compound is covered, prior to filling your pharmacist should submit the claim to Express Scripts electronically. If any ingredient is not covered, the entire compound will not be paid by the plan. If your compounded medication is not covered, you are encouraged to discuss commercially available products with your physician.
• Anorexiants (drugs for weight reduction) such as Lonamin®, Pondimin®, Redux®, Meridia®, Xenical®, Qsymia, Saxenda, Wegovy
• Non-legend drugs other than those listed under "What Drugs Are Covered?"
• Viagra®, Muse®, Cavereject®, Levitra®, Cialis®, Addyi®, or other drugs approved for sexual dysfunction
• Renova®
• Growth hormone for short stature or for adult growth hormone deficiency
• Rogaine®, Propecia® (for similar products whose sole purpose is to stimulate or promote hair growth)
• Drugs labeled “Caution — limited by federal law to investigational use,” or experimental drugs
• Infertility drugs unless authorized by a provider in the Duke Division of Reproductive Endocrinology when covered under Duke Options or Duke Select, and receiving services from Duke Reproductive Endocrinology
• Drugs which are purchased outside of the United States and do not have FDA approval
• Biological sera, blood or blood plasma, or products derived from blood or blood products
• Medical devices and appliances (except glucometers prescribed by your physician)
• Charges for the compounding of any drug that are in addition to negotiated fees
• Over-the-counter items
• Take-home drugs from an inpatient facility
• Replacement of drugs that have been lost, stolen, or destroyed
• Drugs prescribed by provider for himself/herself or his/her immediate family
• Drugs prescribed for cosmetic purposes

In addition, the drugs on this document have been excluded from coverage. This list is current as of January 1, 2023. Changes may have occurred since this date.