Page 10 - 2022 Benefits Resource Guide

Medical, vision & pharmacy benefits, cont.

Mail order prescriptions
The mail order program is another option for filling your maintenance
medication prescriptions. The program provides a 90-day supply of the
prescribed medication and mails it to your home address.

To use the 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.

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