There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician, optometrist, podiatrist or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.
Where you can obtain them. You may fill the prescription at a network pharmacy or by home delivery. To locate a network pharmacy in your area, call 877-438-4449 or visit our Express-Scripts website through our member portal at member.compassrosebenefits.com. For prospective members, please go to www.compassrosebenefits.com/pharmacy. We will send you information on the home delivery drug program. To use the program: 1) complete the initial home delivery form; 2) enclose your prescription and copayment; 3) mail your order to Express Scripts, PO Box 66577, St Louis, MO 63166-6577; 4) allow two to three weeks for delivery. You will receive forms for refills and future prescription orders each time you receive drugs or supplies under this program. If you have questions about the home delivery program, call 877-438-4449. Note: Prescriptions filled by non-network pharmacy providers are not covered by the Plan.
You are required to obtain all specialty drugs used for long term therapy (chronic specialty drugs) from Accredo (home delivery), your exclusive Specialty Pharmacy. Express Scripts can advise you if your prescription is required to be obtained from Accredo and cannot be obtained from a retail pharmacy. Your physician can fax your prescription directly to Accredo at 888-302-1028 or you can mail your prescription to: Express Scripts, P. O. Box 66577, St. Louis, MO 63166-6567. If you purchase your chronic specialty drugs from a retail pharmacy, you will be responsible for their full cost. Note: This does not apply to specialty medications you purchase from a retail pharmacy outside the 50 United States. You file a claim for them as you would for other medications purchased in this manner.
In addition, certain specialty drugs must be obtained from Accredo (home delivery) and not from your prescriber's office or outpatient facility when Medicare B is not your primary coverage for the drug. You or your prescriber can contact Express Scripts at 800-803-2523 to speak to an Accredo representative to inquire if your drug should be obtained through Accredo. If you currently are using a specialty drug supplied by the prescriber’s office or an outpatient facility, you are required to obtain the drug from Accredo after two courtesy fills through the medical benefit. Nursing services are provided by Accredo when necessary. If you continue to purchase your drugs from your prescriber, outpatient facility, or another pharmacy, you will be responsible for their full cost after two courtesy fills. Note: This does not apply to specialty drugs you obtain from a provider or Military Treatment Facility outside the 50 United States. You file a claim for them as you would for other drugs purchased in this manner.
These are the dispensing limitations. You may purchase your covered prescription drugs and supplies by presenting your prescription drug card and your prescription to a participating provider. If obtaining prescription drugs from a VA hospital or military treatment facility, you may obtain a 3-month supply of covered drugs. Refills are allowed by your plan at a retail pharmacy after 80% of the medication is consumed. Refills are allowed by your plan through mail order after 77% of the medication is consumed. The calculation is based on the total amount of medication dispensed in the last 180 days.
If your physician or dentist prescribes a medication that will be taken over an extended period of time, you should request two (2) prescriptions, one for immediate use with a participating retail pharmacy and the other for up to a 90-day supply from the Home Delivery Program. Medications received from the Home Delivery Program must be an 84 to 90-day supply. The Plan also covers an 84 to 90-day supply of covered medications at CVS and Walgreens in addition to Express Scripts home delivery pharmacy. Most drugs and supplies covered by the Plan are available under this program with the exception of specialty medications and fertility drugs. If you have questions about a particular drug or a prescription, and to request your first order forms, call Express Scripts at 877-438-4449. If a generic equivalent to the prescribed drug is available, Express Scripts will dispense the generic equivalent instead of the brand name unless you or your physician specifies that the brand name is required. If there is a generic substitution available and you request a brand-name drug, you will be responsible for the brand copay plus the difference in the cost of the brand-name and generic drug. If your provider’s prescription is for the brand-name drug and indicates “Dispense as Written” you are responsible only for the brand copay. If a generic equivalent is not available, you will be charged the applicable copayment or coinsurance for the medication prescribed. When purchasing drugs at a pharmacy, you must use your health plan member identification (ID) card.
You may be able to obtain certain therapy directly through the pharmacy benefit including but not limited to specialty medications (i.e. gene therapy, antineoplastic agents, immunoglobulin preparations).
We use a formulary. We use the Express Scripts National Preferred Formulary. Preferred Drugs are selected according to safety, efficacy (whether the drug works for the indicated purpose), therapeutic merit (how appropriate the drug is for the treatment of a particular condition), current standard of practice, and cost. Non-Preferred drugs are also on the Formulary, but at a higher copay. Drugs that are excluded from the Formulary are not covered by the prescription drug program unless approved through a Formulary exception process managed by Express Scripts. If approved through the process, the non-preferred copay applies.
The Formulary is the same for both the Home Delivery Pharmacy and the retail network pharmacies and is comprehensive for all major categories of acute and maintenance medications. To find out the Formulary status of a drug, you can either call Express Scripts at 877-438-4449 or look on the web at www.compassrosebenefits.com/Formulary.
We have a six-tier prescription drug benefit.
Level 1: includes generic drugs
Level 2: includes preferred/formulary brand name drugs
Level 3: includes non-preferred/non-formulary brand name drugs
Specialty Generic: includes generic specialty drugs
Specialty Formulary: includes specialty preferred brand name drugs
Specialty Non-Formulary: includes specialty non-preferred brand name drugs
Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original brand name product. Generics cost less than the equivalent brand name product. The U.S. Food and Drug Administration (FDA) sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand name drugs.
How to reach an Express Scripts Specialist Pharmacist. If you have questions on your medications, call 877-438-4449. The pharmacists specialize in caring for patients with complex and costly conditions. This includes but is not limited to cardiovascular, diabetes, cancer, HIV, asthma, depression, and specialty conditions.
Some drugs require prior authorization. A Prior Authorization (PA) is a clinical program that ensures appropriate use of prescription medications. You, your pharmacist or your physician can initiate a PA for medication by contacting Express Scripts Prior Authorization department directly at 800-753-2851 and requesting a PA for the medication. You, your pharmacist or your physician can initiate a PA for medication. Your doctor can also visit www.ESRX.com/PA and complete the information online. Medications subject to a PA require a clinical review and pre-approval from the Express Scripts Prior Authorization Team before they can qualify for coverage under this Program. Medications requiring Prior Authorization are subject to change. Therefore, if you have questions about a particular drug, please contact Express Scripts customer service at 877-438-4449.
Quantity allowances. Specific allowances are in place for certain medications based on FDA-approved prescribing and safety information and clinical guidelines. These include but are not limited to quantity limits, days supply and refill limitations.
Step therapy (non-specialty and specialty). Within specific therapy classes, there are multiple drugs available to treat the same condition. Step Therapy manages drug costs by ensuring that patients try first line, clinically effective, lower-cost medications before they utilize a higher-cost medication. The step therapy program applies edits to drugs in specific classes at the point of sale. Coverage for second-line therapies (second/third step) is determined at the patient level based on the presence or absence of first-line drugs or other automated factors in the patient's claim history.
Express Scripts SafeGuardRxSM Program. The SafeGuardRxSM Program is a suite of solutions that addresses specific chronic therapeutic conditions focused on reducing costs and improving care. The emphasis is on ensuring members are getting appropriate therapy for their condition, adherence and specialized care for better therapy outcomes. These programs may include prior authorization, step therapy, and refill and quantity limits. Some medications may be preferred over others based on FDA indications. These programs may require that you receive your medications from a specific preferred network pharmacy. You may pay a higher cost for your medications at a retail pharmacy after obtaining multiple fills. Medications used to treat high cholesterol and multiple sclerosis are a couple of the targeted therapies. We will incorporate additional therapies where appropriate to address member needs.
In order to manage an affordable prescription benefit, it is important that we are reactive to unnecessary cost increases. Safety and effectiveness of medication will remain a priority, however, one medication may be more cost effective than another. We may act upon an unexplainable cost increase during the year and make medications that are less costly preferred.
Express Scripts Patient Assurance Program (PAP). Compass Rose, through Express Scripts' Patient Assurance Program (PAP), may lower copays on select medications you may receive.
Compound Medications. A compound medication is a compounded prescription in a customized dosage form that contains at least one federal legend drug. You should contact Express Scripts at 877-438-4449 to determine if a compound medication is covered before you fill the prescription.
The U.S. Food and Drug Administration (FDA) defines a compound medication as one that requires a licensed pharmacist to combine, mix or alter the ingredients of a medication when filling a prescription. The FDA does not verify the quality, safety and/or effectiveness of compound medications.
Pharmacies must submit all ingredients in a compound prescription as part of the claim for both online and paper claim submissions. All ingredients submitted with the compound prescription claim must be covered and at least one of the ingredients must require a physician’s prescription for reimbursement.
Prescriptions containing certain ingredients (such as, over-the-counter (OTC) products, bulk powders, kits, solid dosage forms, and proprietary bases) when compounded for dispensing are not covered through the prescription benefit. Investigational drugs are not FDA-approved. If the compound includes an investigational drug, the compound will not be covered.