If you elect medical coverage, you are automatically enrolled in the prescription drug program.
State of Delaware Prescription Coverage
Effective September 1, 2015
|Generic1||Preferred Brand2||Non-Preferred Brand3|
Effective Sept. 1, 2015: Erectile dysfunction medications will not be covered unless medically necessary for a condition other than erectile dysfunction—applies to all plans. Coverage of erectile dysfunction medications for medical necessity requires coverage review.
1 Tier one covers generic products
2 Tier two covers preferred brand name (formulary) drugs
3 Tier three covers non-preferred brand (non-formulary) drugs.
Members must obtain maintenance medications as 90-day fills at a 90-day participating pharmacy or Express Scripts Home Delivery to avoid paying a penalty after a third 30-day fill. Additional information on this program, a list of 90-day participating pharmacies, and information on Express Scripts Home Delivery may be obtained at http://ben.omb.delaware.gov/script/index.shtml. (If the strength of a current prescription is changed, it is considered a NEW prescription.)
The Coverage Review Program ensures that plan participants are receiving prescription medications that result in appropriate, cost-effective care. If you are taking any drugs that are subject to coverage review or copay review, Express Scripts will need to review additional information from your doctor before a decision can be made, if they can fill the prescription medication under your plan.
The coverage review process uses plan rules based on FDA-approved prescribing and safety information, clinical guidelines and ACA guides (Affordable Care Act).
The coverage review process may be necessary:
For more information:
If you have specific questions about medication or pharmacy participation, contact Express Scripts Member Services, 24 hours a day, 7 days a week.
Non-Medicare members: 1-800-939-2142
Medicare eligible members: 1-877-680-4883