You can check to see if the prescription drug you take is on the formulary by logging into your Express Scripts account. You may also call Express Scripts at 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.
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 annual 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). The co-payment will be waived for most contraceptive medications under all of Duke's medical plans. A listing of medications, implants, and IUDs is available here (this listing is subject to change).
No. You are not required to use the Express Scripts Mail Order program. However, you will save money by using the mail order program. You can also purchase long-term maintenance medications (90-day supply) at participating Duke Pharmacies under the same guidelines as Express Scripts Mail Order.
Yes, many injectible prescription drugs are covered with the proper prescription.
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 $15/$50/$70 (depending on the type of drug). Even after 90 days, this $15/$50/$70 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.)
Insulin and diabetic supplies purchased through a retail pharmacy will be charged a co-pay of $15/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 $70 and a maximum of $165) 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 $25 for a 90-day supply throughout the year.
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.
Our pharmacy manager, Express Scripts, consults with your provider for authorization of medications requiring prior approval.
Weight Loss Medications
No. Weight loss medications, including drugs such as Wegovy, Saxenda, Qsymia—or Ozempic and Mounjaro, when prescribed for the purpose of weight loss—are excluded from our Express Scripts pharmacy coverage. Additionally, fees for weight loss programs or costs incurred for weight loss foods/products are excluded from coverage under Duke’s medical or pharmaceutical programs.
Duke has always excluded drugs for weight reduction from the pharmacy plan. The drugs that are currently popular are relatively new, and their medical effectiveness and long-term impact are still being understood. Additionally, because these drugs are highly priced, adding coverage would increase premiums higher than reasonable.
No. At present, 50% of group employers exclude weight loss medications from coverage.
Duke routinely evaluates its benefit programs in order to ensure that the plans offered are competitive in the market and affordably priced for members. Duke continues to review this coverage as new drugs are approved and new clinical studies are published.
LIVE FOR LIFE, Duke's employee wellness program, offers a variety of programs and services to support employees with a specific goal of weight loss. Health Coaching with a certified coach, Nutrition Consultations with a Dietitian, and Fitness Consultations with a Fitness Specialist have been of particular interest to employees seeking weight loss support and are free of charge to benefits eligible employees. For additional information about these programs and many others, contact LIVE FOR LIFE at (919) 684-3136, option 1 or visit the website at LIVE FOR LIFE.