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Prescription Program

Our Prescription Drug Program Policy includes how the formulary is developed and maintained, the prior authorization program, how to pursue an exception, and information on generic substitution and quantity limits. It can be accessed here.

Prescription Drugs

If your plan includes prescription drug benefits from Express Scripts, access your personal prescription information via the Express Scripts website or mobile app.

To register:

  • Go to express-scripts.com and select Register Now or download the Express Scripts Mobile App for free from your mobile device’s app store and select Register Now
  • Complete the information requested, including personal information and customer ID number, create your user name and password, and add security information in case you ever forget your password
  • Click Register Now and you’re registered
  • On the final page, you can set preferences now (including the option to share your prescription information with other adult members of your household (aged 18+) covered under your prescription drug plan) or later in My Account on express-scripts.com
  • Click Continue

Once registered, you'll be able to order prescriptions and check the status of your order, have prescriptions delivered to your home if you have a home delivery benefit, price and compare brand-name and generic medications, and access valuable health and medication information.

  • Go to the Express Scripts Gateway. Make sure your plan includes prescription drug benefits from Express Scripts before you continue. If you are unsure, check with your plan administrator.
  • If you're looking for WPS MedicareRx Plan (Medicare Part D) information, please visit the WPS MedicareRx Plan site area.

Here are some things to keep in mind about prescription drugs

WPS Drug Prior Authorization list
If your drug appears on this list, you and your provider will need to get an approved prior authorization from us. The contact information for a prior authorization can be found on the prior authorization list.
SaveonSP Specialty Drug List
Some WPS group health plans include the SaveonSP program from Express Scripts, which allows you to save on certain specialty drugs. The SaveonSP Drug List includes all medications that are part of the program, along with their individual copays. Please check with your benefits department to find out whether this program applies to you.

2021 WPS Large Group Formulary
2021 Individual and Small Group Formulary
2021 Short-Term Health Plan Formulary
This document provides a list of drugs that are preferred by your WPS health plan. Drugs are listed alphabetically by drug category and name.

What is a drug formulary?

Most plans come with a drug formulary. A drug formulary is a list of prescription drugs, both generic and brand name, used by practitioners to identify drugs that offer the greatest overall value. A committee of independent, actively practicing physicians and pharmacists maintain the formulary. The formulary can change from time to time.

Please refer to your certificate of insurance or individual policy for additional details about your pharmacy benefit and applicable deductibles, copays, and/or coinsurance.

*All benefits are subject to plan provisions such as medical necessity and exclusions. There is no guarantee of payment and usual and customary fees may apply.

What do the different tiers mean?

Drugs on a formulary are typically grouped into tiers. The tier that your medication is in determines your portion of the drug cost. A typical drug benefit includes three or four tiers:

  • Tier 1 usually includes generic medications.
  • Tier 2 usually includes preferred brand-name medications.
  • Tier 3 usually includes non-preferred brand-name medications.
  • Tier 4 usually includes specialty and biosimilar medications (Three-tier programs do not have a unique tier for specialty medications)

A medication may be placed in tier 3 or 4 if it is new and not yet proven to be safe or effective, or there is a similar drug on a lower tier of the formulary that may provide you with the same benefit at a lower cost.

Note: If you have a federally qualified high-deductible health plan, you do not have a tiered drug benefit; your pharmacy and medical expenses are subject to your deductible and coinsurance. This section does not apply to you.

What are generics and biosimilars?

The active ingredients in a generic drug are chemically identical to their brand name counterparts. When an FDA-approved generic is available, a health plan may limit coverage to the generic, and a pharmacist will dispense the generic medication. If an Arise Health Plan customer requests the brand, he/she will be responsible for the difference in cost between the brand and the generic, plus any applicable deductible, coinsurance, and/or copay.

Note: The cost difference between the brand and generic drug is not considered a covered benefit and does not apply to the deductible or out-of-pocket (OOP) maximum.

Biosimilars are drugs approved by the FDA that have no clinically meaningful differences from the originator brand name biologic agent. They provide the same clinical outcome as the brand originator drug and are usually considered specialty medications from a copay perspective.

What is prior authorization and when is it needed?

Prior Authorization is a process that monitors the use of certain drugs to ensure they are prescribed in appropriate clinical situations. Drugs subject to prior authorization typically have safety issues, a high potential for inappropriate use, and/or have lower-priced alternatives on the formulary.

Drugs requiring prior authorization must meet specific criteria for use before they will be considered a covered benefit. The process usually involves these steps:

  1. Your practitioner submits certain medical information to help us make a decision.
  2. Your practitioner’s office and you are notified as to whether or not the drug is approved.
  3. If a drug prior authorization has been denied or not submitted, your pharmacy will not be able to file the drug claim under your prescription benefit, so you will be responsible for the entire cost of the prescription.

What if my drug isn’t on the formulary (exceptions)?

A drug formulary is a list of prescription drugs, both generic and brand name, used by practitioners to identify drugs that offer the greatest overall value. The formulary does not contain a complete list of all available drugs. In addition, some drugs may require a prior authorization prior to coverage while others may not be covered on the formulary.

We have an exception process for individuals to request coverage of a drug that is not on our prescription drug formulary. You, your authorized representative, or prescribing health care provider may request access to clinically appropriate drugs that are not otherwise covered by the health plan’s drug formulary through an approved exception. An exception request can be requested for both urgent and non-urgent circumstances.

If you would like to initiate a formulary exception through your provider, please have them contact Express Scripts for more information or to start a request.

Why is a formulary drug getting rejected?

The following is a list of common reasons a prescription may not process at the pharmacy.

  • Prior authorization is required but has not been obtained.
  • The pharmacy may be submitting the claim under the wrong family member. For example, a prescription for an oral contraceptive will only process if the family member is female.
  • Some drugs, like migraine medications, are not taken every day. If the pharmacy is submitting a quantity larger than what is allowed, the prescription will not process.
  • Retail pharmacies are only able to dispense up to a continuous 30-day supply of medication. If your pharmacy is trying to dispense greater than this amount, the prescription will not process.

To answer your specific questions, please contact Express Scripts Customer Service for more information.

If your health plan includes a prescription drug home delivery benefit, you can find answers to common questions here.

How do I submit a prescription to the home delivery pharmacy

  1. Obtain a written prescription from your doctor. Make sure your doctor writes the prescription for up to a 90-day supply of your medication (or for the maximum days supply allowed by your benefit). The prescription should include refills for up to one year, if appropriate.
  2. Write the patient’s name, ID number, address and date of birth on the prescription.
  3. Download the Express Scripts® Home Delivery Order Form and follow the instructions.
  4. Attach your written prescription to the form as indicated.
  5. Mail the order form and written prescription to this address:

What if I do not have a written prescription?

Your doctor will need to verify the Patient Information, attach your new prescription, and fax your order to Express Scripts at 1-800-521-5779. This must be faxed from your doctor’s office. Faxes sent from other locations (such as your home or workplace) will not be accepted.

How do I order refills?

You can order refills by visiting express-scripts.com. You will need to log into your account and click on "Order Refills" under "My Prescriptions."

If it's too soon to refill your prescription, the Express Scripts website will show you the date on which you can order a refill.

What if I will be out of town for a prolonged period of time and will need a refill before I return?

If you obtained your original prescription from a national chain pharmacy (e.g., Wal-Mart, Osco), you can refill your prescription at any one of their stores nationwide. If you do not use a national chain, or one is not available in the temporary location, you may wish to obtain your maintenance medications from the Express Scripts home delivery where you can get up to a 90 consecutive day supply. If neither of these options is feasible, you may contact Customer Service toll-free at 1-888-711-1444, option #1, to consider other alternatives.

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