(For Active Employees And Non-Medicare Retirees)
The State of Delaware list of covered medications (formulary) may change periodically.
Express Scripts reviews and updates the plan's list of covered medications every year to ensure that the plan is providing the most effective medications for members at the most reasonable cost to the State of Delaware.
There are now a number of brand medications that are excluded from the State of Delaware's formulary. This means these drugs are no longer covered under the State plan, and members must pay the total retail cost of the medication. If an excluded medication is medically necessary, you may initiate a Coverage Review.
2017 Formulary Information
Rates effective September 1, 2015
|Prescription Coverage||30-Day Supply||90-Day Supply|
Cost Savings With 90-Day Prescriptions: You'll pay only 2 times your 30-day retail co-payment if you order up to a 90-day supply of covered medication at a 90-day participating pharmacy or through Express Scripts mail order service, Express Scripts Pharmacy. Please note: (1) You are required to fill certain long-term medications using 90-day fills or you will pay a penalty copay (Maintenance Medication Program). (2) Not all medications are available in a 90-day supply.
You may have your prescriptions filled at any pharmacy that participates in the Express Scripts network. If the pharmacy is also a 90-day participating pharmacy, you may fill maintenance or other prescriptions for up to a 90-day supply. If the pharmacy is not a 90-day participating pharmacy, you can fill prescriptions for up to a 60 day supply.
To verify coverage at a particular pharmacy, check the Express Scripts Website or call 1-800-939-2142.
To have a new prescription filled through the Express Scripts Pharmacy:
For more information, call Express Scripts Customer Service at 1-800-939-2142 (if you are not enrolled in Medicare) or 1-877-680-4883 (if you are enrolled in Medicare).
Worry-Free Fills Program, the Express Scripts automatic refill service, helps address one of patients' main sources of anxiety when using mail order –fear of running out of medication because they forgot to refill or the medication was not delivered when expected. With Worry-free Fills, patients no longer need to worry; the Express Scripts Pharmacy automatically delivers refills to the patient when the medication's supply is due to run out. And when the prescription is out of refills, we contact the doctor for a new prescription. This helps avoid gaps in care that can affect a patient's health.
This service is completely voluntary, and applies only to mail-order prescriptions. There is no additional cost for the service, and the service can be discontinued at any time.
How Worry-free Fills Works:
Some health conditions require medications that are classified as "specialty medications" and are provided through Accredo and Biotek Remedys Specialty Pharmacy. For example, medications used to treat some forms of cancer, multiple sclerosis (MS), hepatitis C, and rheumatoid arthritis are classified and administered as specialty medications. Members may receive their first 30-day fill of a new specialty medication through a retail pharmacy, but must have subsequent refills of the same medication provided by Accredo or Biotek Remedys. Staff from Accredo or Biotek Remedys will reach out to physicians and members to work together in managing the member's prescription needs.
When a member receives medication through Accredo or Biotek Remedys, a patient care coordinator is assigned to that member. The member is welcome to contact the assigned patient care coordinator to discuss his/her prescription needs and health condition. Prescriptions are delivered directly to a member's home with unique packaging, as necessary, to ensure safety.
Accredo's dedicated customer service number is 1-800-803-2523.
Biotek Remedys is located in New Castle, DE and their customer service number is 1-877-246-9104.
Certain medications may not be covered unless you have first tried another medication or therapy. To obtain the preferred alternative medication, contact Express Scripts Customer Service at 1-800-939-2142. If the preferred alternative medication does not show in your prescription history with Express Scripts, then your doctor will need to provide additional information before coverage can be authorized.
Quantity rules are in place for many medications, and coverage review is required to request additional quantities. In addition, quantities for narcotics and other controlled substances are limited to comply with Federal Food and Drug Administration guidelines. To find out in advance if a drug has a quantity limit, contact Express Scripts Customer Service at 1-800-939-2142.
Specialty medications are usually injectable medications that require special handling or safety protocols. Some specialty medications are appropriate only for limited conditions or certain patient characteristics. Preferred Specialty Management uses prior authorization and step therapy to ensure that members are taking the most clinically appropriate, cost-effective medication first. To find out which specialty medications are appropriate when other alternatives are ineffective or cannot be used, contact Express Scripts Customer Service at 1-800-939-2142.
Compound medications covered under your prescription plan are created to fit unique member needs by combining or processing appropriate ingredients as prescribed by a physician. For example, the form of a medication may be changed from a solid pill to a liquid, or the medication may be customized to avoid a non-essential ingredient that the patient is allergic to.
The copay for all compound medications is the preferred brand copay of $28 for a 30-day supply; $56 for a 90-day supply. The ingredients that (1) are not approved by the FDA for use in compounds, or (2) have experienced significant unjustified cost increases, are not covered under your plan. For more information contact Express Scripts Customer Service at 1-800-939-2142. If your compound medication includes a non-covered ingredient, your doctor can write a new prescription using only covered ingredients. If there is a medical reason that you must take a non-covered medication, your doctor can file an appeal with a letter of medical necessity.
Filling a compound prescription:
If you use a non-network compounding pharmacy, you must pay out of pocket for your prescription and submit a direct claim to Express Scripts for partial reimbursement, based on the maximum allowable cost for the total ingredients.
This program allows you to purchase a brand medication when a generic equivalent is available; however, you will pay the generic copay plus the cost difference between the generic and the brand medication.
If there is a medical reason why you cannot take the generic equivalent, you, your doctor or your pharmacist may initiate a coverage review to allow you to obtain the brand name drug at the non-preferred copay. These authorizations are effective for a one-year period, and must be submitted for renewal annually.
People vary widely in how they respond to medications. A dose that could help one patient might be dangerous for another, and useless for a third. Certain medications need to be converted by enzymes in the liver in order to do what they are supposed to do, and each of us has different amounts of those enzymes.
Genetic testing has been developed to help doctors prescribe the most appropriate drug and dosage for each patient's condition. If you are given a new prescription for medication covered by the Personalized Medicine Program - such as Coumadin /warfarin (blood thinners) or Plavix/clopidogrel - a pharmacist will contact your doctor to see if it is appropriate for you to participate in the program. If your doctor agrees, you will then be contacted by a pharmacist to let you know that the testing is available.
If you agree to participate, you will receive a cheek swab test that you can administer on your own. It's as simple as rubbing a swab on your cheek and mailing it back in an envelope. The results will be sent to your doctor and to a specially trained Express Scripts pharmacist who can help your doctor interpret the results of the test. Of course, your doctor decides which drug and dose is right for you.
The Personalized Medicine Program is available to you at no additional cost, and it requires no action on your part. To find out more, contact:
Express Scripts Customer Service: 1-800-939-2142
Statewide Benefits Office: 1-800-489-8933
Members receiving any infertility service, including but not limited to in-vitro fertilization (IVF) and artificial insemination, are required to pay a 25% coinsurance for health care and prescriptions associated with all infertility services. There is a $15,000 lifetime maximum for all prescriptions for infertility under the State of Delaware prescription plan.
The prescription provider, Express Scripts, will track medications to determine when the lifetime maximum of $15,000 has been reached. Members are responsible for paying 25% coinsurance for all prescriptions at the time of pick up or mail order.
Note: Members who were notified in 2010 that they are grandfathered to retain a lifetime maximum of $30,000 are not responsible for the 25% coinsurance on health care and 25% coinsurance for prescription services. Expenses for grandfathered members will be tracked by the health care provider for both health care services and prescriptions.
If you are charged incorrectly or have additional questions, please contact the Statewide Benefits Office at 1-800-489-8933.
Some medications (as well as diabetic medications and supplies described under "Diabetic Program") are covered through Medicare Part B for those enrolled in Medicare Part B. For retirees, prescriptions for these medications and supplies will be processed first through Medicare Part B and second through Express Scripts Medicare at the time of purchase.
For active employees enrolled in Medicare due to End-Stage Renal Disease (ESRD), the claim will first be processed through Medicare Part B and pay at 80%, with the member responsible for the remainder of the cost at the time of purchase. Reimbursement of the 20% may be obtained by submitting a Coordination of Benefits/Direct Claim Form, with receipts, to Express Scripts.
Questions about specific medications and supplies covered through Medicare Part B may be answered by calling Express Scripts Customer Service at 1-800-939-2142 (active employees), or Express Scripts Medicare at 1-877-680-4883 (retirees).