Page 11 - 2023 Employee Benefits Guide

Prescriptions that are not maintenance medications
You can fill prescriptions that are not maintenance medications at any
retail pharmacy or through the Express Scripts mail order program for
the applicable copayment. See the chart below for copayment amounts.

Mail order prescriptions
The mail order program can be used to fill any prescription, including
maintenance medication prescriptions. To use program, ask your
physician to write a prescription for a 90-day supply with refills (as
appropriate) and to send it to Express Scripts. Otherwise, obtain a mail
order form from Express-Scripts.com and follow the instructions for
mailing your prescription and copayment to Express Scripts. Once
processed, Express Scripts will mail your medication to your home.

Prescription medication tiers
Express Scripts categorizes prescription medication as Tier 1 (Generic),
Tier 2 (Preferred Brand), or Tier 3 (Non-preferred Brand). The cost of
the medication is not a primary factor in its tier classification. A
medication’s classification may change periodically. You can find up-to-
date prescription medication tiers on Express-Scripts.com, by using
the Express Scripts mobile app, or by contacting Express Scripts’
customer service.

Prescription copayments

Network Pharmacy Smart90 Rx
Benefit Specialty (at Walgreens) Non-Network Pharmacy
Pharmacy Mail Order

Supply Limitation 30 Day 90 Day 30 Day

Tier 1 (Generic) $10 $20 $10 + 20% of negotiated price

Tier 2 (Preferred Brand) $40 $85 $40 + 20% of negotiated price
Tier 3 (Non-preferred Brand) $60 $125 $60 + 20% of negotiated price

Generic vs. brand-name prescription medications

When a medication is available in generic form (Tier 1), but your
physician prescribes the brand-name medication (Tier-2 or Tier-3), you’ll
be charged the generic copayment plus the difference in cost between
the generic and brand-name medication.

If you request a brand-name drug when the physician approves an
available generic drug, you’ll be charged the brand copay plus the
difference in cost between the prescribed brand-name medication and its
generic (Tier-1) equivalent.

Employee Benefits Guide 7