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Microsoft word - redlands benefit summary 2013 _3_
The following outline of your group’s outpatient prescription drug benefit is provided for your information. This document contains specific coverage and exclusion information related to your prescription benefit provided by Redlands USD and administered by Express Scripts, Inc. For more information about these drugs or others, you can reach us by calling 1-877-586-3115 or by going to express-scripts.com. Just click on “Member Services” and login using your member ID. For more general information about drugs, vitamins and your health conditions, log on to express-scripts.com and select “DrugDigest.”
Benefit design as of July 2013
Retail Copayments -30 Day Supply
Mail Service Copayments – 90 Day Supply
Effective 07-01-2013 Preferred Home Delivery
Generic/Brand Maintenance Drugs
Filled at Retail Pharmacy after 2 fills– 30 Day supply
Generics Preferred –
Member will pay copay plus an ancillary fee (difference in cost between the brand and the
generic) if the member and not the Physician chooses brand over a generic drug. If Physician specifies brand only there
– All specialty medications must go through CuraScript Pharmacy after two fills at retail. Please call
1-866-848-9870 if you are on a specialty injectable medication or specialty drug. Prior Authorization
– Prior authorization is needed for certain medications – please refer to the back of this page
for more details.
- Prescription Drug benefits are not payable for the following items:
All over-the-counter products & drugs Diagnostic, Testing & Imaging
Contraceptive emergency age >17 & IUD
**The following OTC drugs are covered: Diabetic Supplies, Peak Flow Meters, Non Insulin Syringes, and
Respiratory Therapy Supplies
Prior authorization is needed for certain medications. If you have questions on a particular drug, please contact
Customer Service or visit express-scripts.com to perform a coverage check. Please have your doctor call Express Scripts
at 1-800-417-8164 to go through a clinical review on your medication if it is subject to prior authorization.
Prior Authorization is a program
that helps you get the prescription drugs you need with safety, savings and — most
importantly — your good health in mind.
It helps you get the most from your healthcare dollars with prescription drugs
that work well for you and that are covered by your pharmacy benefit
. It also helps
control the rising cost of
prescription drugs for everyone in your plan.
The program monitors certain prescription drugs to ensure that you are getting the appropriate drugs for your disease
state. It works much like healthcare plans that approve certain medical procedures before they’re done, to make sure
you’re getting tests you need: If you’re prescribed a certain medication, that drug may need a “prior authorization.” It
makes sure you’re getting a cost-effective drug that works for you.
For instance, prior authorization ensures that
covered drugs are used for treating medical problems rather than for other purposes.
When you have a prescription filled, your plan will cover the use of formulary and non formulary products.
If you use one of the non-formulary (or non-preferred drugs on the list) it will be covered at a higher copay.
For a copy of the formulary, please call Express Scripts at 1-877-586-3115 or visit express-scripts.com to perform a
Drugs in certain categories could be subject to Step Therapy. Step Therapy is a program in which certain drug classes
are organized in a set of “steps” with generic drugs being the first step and brand name drugs being the second step.
ACE Inhibitors: ie - Accupril, Zestril, Monopril, Lotrel
Selective Serotonin Reuptake Inhibitors – SSRI Antidepressants: ie: Celexa, Prozac, Zoloft
Branded NSAIDs: ie – Arthotec, Mobic, Ponstel
Calcium Channel Blockers – Dihydropyridine Products: ie - Adalat CC, Dynacirc, Sular
HMG – Enhanced: ie – Lipitor, Zocor, Pravachol, Caduet
Proton Pump Inhibitors: ie – Aciphex, Nexium, Prevacid, Zegerid, Protonix
Express Scripts’ Home Delivery Pharmacy - Your plan has Preferred Home Delivery if you choose to
fill your medication through a retail pharmacy after two fills you will pay a higher copay.
Save money by ordering up to a three-month supply of your medication.
Pharmacists check every prescription for accuracy and potential drug interactions.
Talk confidentially to a pharmacist 24 hours a day, every day.
Order refills easily by mail, phone or online.
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