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Sometimes, the medical community determines more than one prescription drug is safe and effective for the treatment of the same illness or injury. WPS 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.”

See our Step Therapy tip sheet.

This information only applies if your pharmacy benefits are managed through Express Scripts Inc (ESI). If you are unsure who manages your pharmacy benefits or do not have pharmacy benefits through ESI, please contact your Human Resources department for more information.

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.

Preventive medications required under the Affordable Care Act are available at no cost to the member.

• Tier 1 usually includes preferred generic medications.
• Tier 2 usually includes other generic medications.
• Tier 3 usually includes preferred brand-name medications.
• Tier 4 usually includes non-preferred brand-name and non-formulary medications.
• Tier 5 usually includes specialty and biosimilar medications.

A medication may be placed in tier 4 or 5 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. Some groups also have access to a Tier 0 that includes additional high-value drugs for the prevention and/or treatment of certain conditions at as low as $0 cost to the member.

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 a WPS member requests the brand, they 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. Learn more.

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:

• Your practitioner submits certain medical information to help us make a decision.
• Your practitioner’s office and you are notified as to whether or not the drug is approved.
• 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.

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 healthcare 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.

• Prior authorization is required but has not been obtained.
• 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 may 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.