Express Scripts Medicare Formulary

Express Scripts, now part of Evernorth, manages one of the nations largest Medicare prescriptiondrug plans. The formularyits list of covered medicinesis a core tool that helps seniors, their caregivers, and prescribers understand which drugs are covered, at what cost, and under which conditions. This page explains the key features of the ExpressScripts Medicare formulary, how it is organized, and what you need to know to make the most of your benefits.

Why a Formulary Matters

A formulary is not a blacklist. Instead, it is a tiered catalog that balances clinical effectiveness, safety, and cost. By placing drugs into tiers, the plan can encourage the use of equally effective, lowercost alternatives while still providing access to brandname therapies when they are the best option.

How the Formulary Is Structured

Express Scripts Medicare uses a standard fivetier structure. The tiers are described below, followed by an example of typical drugs in each tier.

Tier	Typical Cost Share	Drug Types
Tier 1	$0$5	Generics, highvolume, lowcost drugs
Tier 2	$15$30	Preferred brandname drugs, some specialty generics
Tier 3	$40$70	Nonpreferred brandname drugs
Tier 4 (Specialty)	$250$500+	Highcost specialty therapies (e.g., biologics, injectables)
Tier 5 (NonFormulary)	Not covered	Drugs not on the formulary may be covered only with prior authorization or under a cash pay option

Key Features of the Express Scripts Medicare Formulary

1. Broad Coverage of Generics

Over 90% of generic drugs are placed in Tier1, ensuring minimal outofpocket costs for essential medications such as lisinopril, metformin, and amoxicillin.

2. Preferred BrandName List

Express Scripts negotiates contracts with manufacturers to create a preferred list. Drugs on this list appear in Tier2, offering lower copays than comparable nonpreferred brands.

3. Specialty Pharmacy Integration

Tier4 covers specialty medications that require special handling, monitoring, or administration. The plan provides a dedicated specialty pharmacy team that assists with prior authorizations, infusion coordination, and patient education.

4. Prior Authorization (PA) and Step Therapy

For certain highcost drugs, the plan may require a PA or steptherapy protocol. This means a prescriber must first try a lowercost alternative before the requested medication is approved. The PA process is electronic and typically resolved within 48hours.

5. Formulary Updates

The formulary is reviewed and updated annually, usually effective January1 each year. Changes are communicated via a mailed Summary of Benefits and Coverage (SBC) and through the member portal.

How to Find Out If Your Medication Is Covered

1. Use the Online Formulary Tool. Log into Express Scripts member portal and search by drug name or NDC code.
2. Call Customer Service. The tollfree number on your ID card provides live assistance for formulary questions.
3. Ask Your Pharmacy. Most chain pharmacies have access to the latest formulary data and can tell you the tier and any required authorizations.

What To Do If Your Drug Is Not Covered

If a medication appears in Tier5 or is marked nonformulary, you have several options:

• Submit a Formulary Exception. Your prescriber can request an exception if the drug is medically necessary and no suitable alternative exists.
• Switch to a Therapeutic Alternative. The plans formularies often include drugs with the same clinical effect but at a lower tier.
• Consider a CashPay Option. Some pharmacies may offer a discount price for nonformulary drugs, though this can be expensive.

Impact of the Formulary on OutofPocket Costs

Because the Medicare PartD benefit includes a coverage gap (donut hole), staying in lower tiers can dramatically reduce total yearly expenses. Below is a simplified example of how tier placement can affect costs for a common condition (type2 diabetes):

Medication	Tier	Typical Monthly Copay	Annual OutofPocket (Before Gap)
Metformin (generic)	1	$5	$60
Glipizide (generic)	1	$5	$60
Jardiance (brand, preferred)	2	$25	$300
Invokana (brand, nonpreferred)	3	$55	$660

Choosing a Tier1 generic whenever possible saves hundreds of dollars, especially for chronicuse medications.

Resources for Medicare Beneficiaries

• Medicare Plan Finder compare formularies across plans.
• Express Scripts Medicare Member Center access formulary lookup, claims, and PA tools.
• National Institute on Minority Health and Health Disparities resources for culturally appropriate medication counseling.

Frequently Asked Questions

Q: Can I appeal a denied prior authorization?

A: Yes. You have up to 30days to request an internal appeal. If the internal appeal is denied, you may file an external review with the Medicare PartD Appeals Council.

Q: Are overthecounter (OTC) items covered?

A: Generally, OTC products are not covered unless they are part of a specific medicalnecessity exception (e.g., certain vitamins for a diagnosed deficiency).

Q: What happens if I change pharmacies?

A: The formulary is the same regardless of pharmacy, but your copay may differ based on the pharmacys contract pricing. Using a pharmacy within the Express Scripts network often yields the lowest cost.

Bottom Line

The Express Scripts Medicare formulary is designed to provide highquality, costeffective medication options while ensuring that needed brand or specialty drugs remain accessible. Understanding the tier system, keeping track of priorauthorization requirements, and regularly reviewing your medication list can help you stay within budget and avoid surprise costs during the coverage gap.