Am I subject to a pharmacy deductible?
If you purchase your prescriptions through a retail pharmacy and are using either brand or non-formulary drugs you will be subject to a $100 per person deductible. Once you have met the deductible, a co-payment for each prescription will still apply. The deductible does not apply for generic drugs or for long-term prescriptions (90 day supply) filled through a participating on-site Duke Pharmacy or mail order (except for Duke Basic members).
Am I required to use the Express Scripts Mail Order program for my maintenance drugs?
No. You are not required to use the Express Scripts Mail Order program. However, you will save money by using the mail order program. As of March 1, 2010, you can also purchase long-term maintenance medications (90 day supply) at participating Duke Pharmacies under the same guidelines as Express Scripts Mail Order.
How do I find out if the prescription drug that I am taking is on the Express Scripts Health formulary? If it is not on the formulary, what are my choices?
You can check to see if the prescription drug you take is on the formulary, by logging into the Express Scripts website or by calling 1-800-717-6575.
If your prescription drug is not on the formulary, you can talk with your doctor to see if it would be appropriate to change to a drug that is on the formulary or to a generic in the same class.
If you and your doctor agree that a change should be made, you will be required to pay the applicable co-payment (for generic drugs) or the applicable deductible and co-payment for brand formulary drugs.
Are injectibles, like insulin, covered under mail order?
Yes, many injectible prescription drugs are covered under the mail order program with the proper prescription.
Can I order Controlled Substances through mail order? I am now required to present a prescription monthly for this drug.
You are not required to order controlled substance prescriptions through mail order. At a local pharmacy you will be charged the initial co-payment and $100 deductible if your prescription is for a brand. The pricing structure is $10/$40/$55 (depending on the type of drug). Even after 90 days, this $10/$40/$55 co-pay structure will remain for controlled substances. (This is different from regular maintenance medications, which have an increased co-pay after the first 90 days if you continue to purchase at a retail pharmacy.)
I take insulin and use other diabetic supplies. How much will I pay for these items?
Insulin and diabetic supplies purchased through a retail pharmacy will be charged a co-pay of $10/month for the first 90 days. After the first 90 days, a co-pay of 50% of the cost of the drug (with a minimum of $55 and a maximum of $125) along with a $100 annual deductible will apply. However, if you purchase these items through the Express Scripts Mail Order program or a participating on-site Duke Pharmacy, your total out of pocket costs will be $20 for a 90-day supply throughout the year.
I am taking medicine that is part of Step Therapy. Will I be required to change my medication to a generic drug or target brand drug?
If you are taking a medicine that is not currently designated as a generic or target brand drug you will be required to change your medication and go through the step process, or have your doctor complete the required paperwork with Express Scripts indicating that you already tried the step process and it did not work. Please contact Express Scripts for the required paperwork at 1-800-717-6575.
Note: If you are currently on medications for depression you will not be required to change your medications and "step down" to other drugs within the plan target list.
Who provides the authorization for the medications requiring prior approval?
Our pharmacy manager, Express Scripts, consults with your provider for authorization of medications requiring prior approval.