What the Plan Covers
Is It Covered?
If you are not sure if a particular drug is covered, contact Express Scripts at 800-718-6590. There are some prescriptions that require prior authorization.
Covered expenses under the Prescription Drug Plan consist of drugs and medicines approved by the Food and Drug Administration for general use by the public that require a written prescription by a physician and that are dispensed by a licensed pharmacist, physician, or hospital for take-home purposes. Eligible drugs and medicines include:
  • Drugs that require a prescription, except those specifically excluded under What The Plan Does Not Cover;
  • Compound drugs that contain at least one prescription drug;
  • Insulin, including hypodermic needles and syringes when insulin is also purchased;
  • Over-the-counter diabetic supplies, including items used for daily blood and urine sample testing (except diabetic monitors);
  • Retin-A for patients through age 25 (over age 25 when medically necessary);
  • Vitamins that require a prescription;
  • Attention Deficit Disorder drugs (e.g., Methylphenidate, Dextroamphetamine, Methamphetamine, Dextroamphetamine/Amphetamine);
  • Smoking deterrents that require a prescription (e.g., Habitrol, Nicoderm, and Prostep anti-smoking patches);
  • Anorexiants with prior authorization; and
  • 50% coverage for fertility, oral contraceptive, sexual dysfunction, and memory enhancement drugs, unless these drugs are specifically authorized by your physician as medically necessary. Medically necessary drugs are covered at standard reimbursement rates.
Medically Necessary
The Prescription Drug Plan only covers services and supplies that are Medically Necessary. For the purpose of this Plan, Medically Necessary services and supplies are those provided by a hospital, physician or other provider that: (i) have been established as safe and effective; (ii) are furnished in accordance with generally accepted professional standards to treat illness or injury, and are in accordance with the accepted standards of medical practice in the geographic area where the services are provided; (iii) are consistent with the symptoms and diagnosis or treatment of the illness, injury or condition; (iv) are furnished at the most appropriate level that can be provided safely and effectively to the patient; and (v) are not furnished primarily for the convenience of the patient, the attending physician or other provider. Medically Necessary prescriptions will be paid at the standard level or rate of coverage.
How New Prescription Drugs Are Added
The Prescription Drug Plan covers all prescription drugs approved by the Food and Drug Administration (FDA), as long as they are used in the FDA-approved manner and are used in accordance with manufacturers' usage guidelines. Coverage for new prescription drugs will begin upon FDA approval.