Each of Lehigh’s medical plans includes prescription drug coverage through Express Scripts, Inc.
- The prescription drug plan covers medications that require a prescription by either state or federal law and that are prescribed by a licensed practitioner. Insulin, insulin syringes, and needles are covered by prescription only.
- Covered individuals pay a percentage of the average wholesale price (AWP) for each prescription filled, and the plan does not limit the number of prescriptions received beyond restrictions of medical necessity, applicable legislation, or plan guidelines.
- Up to a 30-day supply of covered medication can be dispensed at a retail pharmacy (some restrictions apply). In addition, participants can receive a 90-day supply of covered medications through the mail order prescription program, known as The Express Scripts Pharmacy.
- Express Scripts uses a Preferred Drug Step Therapy Program to help manage the cost of prescription drug coverage.
- See below for important coverage exclusion information.
For all covered drugs, you pay:
Generic: 10% ($25 maximum) per 30-day supply/10% ($75 maximum) per 90-day supply
Formulary Brand Name: 20% ($50 maximum) per 30-day supply/20% ($150 maximum) per 90-day supply
Non-Formulary Brand Name: 30% ($100 maximum) per 30-day supply/30% ($300 maximum) per 90-day supply
Use the search tool to look up your prescription medications to see what category they will be in under the three-tier formulary.
The Express Scripts Pharmacy: You may order 90-day supplies of your prescription drugs via mail through the Express Scripts Pharmacy. The costs are the same as those listed above for 90-day supplies within each category.
Important Coverage Exclusion Information
Express Scripts maintains a list of drugs that they will not cover. In most cases, if you fill a prescription for one of the 2017 Preferred Drug List Exclusions, you will pay the full retail price.
The following are also examples of drugs or other charges not covered under the Express Scripts prescription plan:
- Medications lawfully obtainable without a prescription — excluding insulin
- Devices or appliances (except for diabetic supplies) — support garments or other non-medicinal substances
- Administration charges for drugs or insulin
- Cosmetic drugs and medications used for cosmetic purposes (e.g., Rogaine [Minoxidil] for hair restoration and Retin-A for individuals over 19 years of age)
- Investigational or experimental drugs
- Unauthorized refills
- Vitamins and dietary supplements
- Non-insulin injectables
- Prescriptions covered without charge under Federal, State, or local programs including Worker’s Compensation
- Medications for eligible individuals confined to a rest home, nursing home, sanitarium, extended care facility, hospital, or similar entity.
Please note that this listing is neither exhaustive nor all inclusive.