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.
If your plan includes prescription drug benefits from Express Scripts, access your personal prescription information via the Express Scripts website or mobile app.
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.
Sometimes, the medical community determines more than one prescription drug is safe and effective for the treatment of the same illness or injury. WPS Health Insurance or WPS Health Plan may require you to start with a less expensive prescription drug before benefits are payable for an alternative prescription drug. This helps ensure your medication is effective and affordable. We refer to this as “step therapy.”
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.
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:
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 HSA 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.
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 WPS 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.
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:
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.
The following is a list of common reasons a prescription may not process at the pharmacy.
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.
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.