Express Scripts Medicare PDP maintains a nationwide pharmacy network. Members must use the network pharmacies to fill prescriptions. Covered Medicare Part D drugs are available at non-network pharmacies only in special circumstances, such as illness while traveling outside of the plan’s service area where there is no network pharmacy. Members may have to pay additional costs for drugs received at non-network pharmacies.
Veterans Affairs (VA) Pharmacies are not included in Medicare Part D pharmacy networks. If you are eligible for VA benefits, you can still use VA pharmacies under those benefits. However, the cost of medications purchased at a VA pharmacy will not count toward your Express Scripts Medicare yearly out-of-pocket maximum. Review your Express Scripts Medicare benefit against your VA benefit to determine the best option for you. You may use your VA benefit at your VA pharmacy or transfer your prescription(s) to an Express Scripts Medicare network pharmacy.
This plan maintains a broad choice of covered drugs through the Medicare PDP formulary. The drug formulary is a list of FDA-approved generic and brand-name prescription drugs and supplies covered by your health insurance plan. ESI places covered drugs into three levels: preferred generic, preferred brand or non-preferred.
Preferred drugs are covered at a lower cost to you. Non-preferred drugs are covered, but you will pay more than if you choose preferred brand or preferred generic drugs. If your health care provider prescribes a non-preferred drug, discuss preferred alternative options with your provider.
The formulary list is available here (2023 Formulary) or by contacting ESI, and can change throughout the year.
Medicare Part B drugs are covered by the UnitedHealthcare® Group Medicare Advantage (PPO) plan rather than by Express Scripts. Generally, drugs covered under Medicare Part B are drugs you wouldn’t usually give to yourself. These include drugs you get at a doctor’s office or hospital outpatient setting. A few examples of Part B drugs include vaccinations like flu shots (covered at 100%), drugs used with a DME item, injectable and infused drugs, transplant drugs, and certain oral cancer drugs and anti-nausea drugs. For Medicare covered Part B drugs not covered as a preventive service, you will pay a 20% coinsurance.
There are some drugs that are not covered. These drugs have a covered alternative option that can be discussed with your provider. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price. Your provider may request a clinical exception to cover the drug by calling Express Scripts’ Prior Authorization Line. Approved exceptions are covered as a non-preferred drug.
Members can fill a prescription from any physician at a network pharmacy or through home delivery and may receive up to a 90-day supply of certain maintenance drugs.
Members will receive additional plan information directly from Express Scripts Medicare, including a benefit overview, formulary, pharmacy directory and monthly explanations of benefits.
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