| Generic Formulary: |
$8 |
| Brand Formulary : |
$35* |
| Non-Formulary: |
$55 |
* If for any reason you purchase a brand name drug and a
generic drug is available, you pay the generic copayment ($8)
plus the difference in the cost of the drugs.
Example:
If the generic drug costs $69 and the brand name drug costs
$93, you pay:
| Generic Copayment: |
$8 |
| Cost difference: |
$24 |
| Your total cost: |
$32 |
If you purchase a second
step drug without
completing step
one, you pay the full cost of the drug.
If a copayment amount is more than the cost of the drug, you
pay the cost of the drug.
A limited number of local network pharmacies offer up to a
90-day supply for two and a half copayments. Call ESI at 800.797.5754
to locate a 90-day pharmacy.
Mail Order
The mail order benefit covers up to a 90-day supply of maintenance
medications for two and a half
copayments.
| Generic Formulary |
$20 |
| Brand Formulary |
$87.50* |
| Non-Formulary |
$137.50 |
This may not apply to drugs which require prior
authorization or quantity
level limits.
CuraScript Pharmacy, Inc., is Express Scripts’ mail
order pharmacy provider for specialty prescriptions. Specialty
drugs are high cost and are primarily self-injectible but
sometimes oral medications. If your prescription is transferred
to CuraScript Pharmacy for processing, you are assigned a
Patient Care Coordinator who:
- Follows your prescription needs.
- Monitors your progress.
- Communicates with your providers.
- Coordinates with Express Scripts, Inc.
Retail
and Mail Order Coverage also includes:
- Diabetic supplies such as:
- Insulin.
- Syringes.
- Test strips.
- Lancets.
- Glucometers.
- Certain vitamins (not over-the-counter), self-injectables,
oral chemotherapy agents, and hematopoietic stimulants.
- Growth hormones with prior authorization.
- Infertility drugs with 50% member coinsurance.
- Smoking cessation prescriptions (formulary) - limited
to $500 annual benefit.
For more detailed information,
contact ESI.
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