Learn About Express Scripts Pharmacy Benefits

What Express Scripts Does as a Pharmacy Benefit Manager

Express Scripts is one of the largest pharmacy benefit managers (PBMs) in the United States. A pharmacy benefit manager is a company that works between insurance companies, employers, and pharmacies to manage prescription drug coverage. If your health insurance plan includes prescription drug coverage, Express Scripts may be the company managing those benefits behind the scenes.

Express Scripts handles several key tasks related to prescription medications. The company processes claims when you fill prescriptions at pharmacies. This means when you hand your insurance card to a pharmacist, Express Scripts' systems verify your coverage, check whether your medication is covered under your plan, and determine how much you pay out of pocket. The company also maintains formularies, which are lists of medications that your insurance plan covers.

The company negotiates prices with pharmaceutical manufacturers and pharmacies. These negotiations can affect what medications are available to you and how much you pay for them. Express Scripts also manages mail-order pharmacy services, allowing customers to receive medications delivered to their homes. This service is often used for medications people take regularly, such as blood pressure or diabetes medications.

Express Scripts operates in all 50 states and serves millions of people through employer health plans, Medicare plans, and Medicaid programs. The company processes more than 2 billion prescriptions annually, according to industry data. Understanding how Express Scripts works can help you navigate your prescription drug coverage more effectively and find ways to manage medication costs.

Practical Takeaway: Express Scripts is likely managing your prescription drug coverage if you have health insurance through an employer or government program. Knowing this helps you understand who to contact with prescription coverage questions.

How Formularies and Medication Coverage Work

A formulary is a list of medications that Express Scripts' plans cover. Think of it as a menu of approved drugs. Each health plan has its own formulary, which means medications covered under one plan may not be covered under another. Express Scripts creates and maintains these lists for the insurance plans they work with.

Formularies are organized into tiers, typically ranging from 1 to 5. Each tier has different out-of-pocket costs for patients. Tier 1 usually includes generic medications, which are the least expensive and have smaller copayments or coinsurance amounts. Tier 2 contains preferred brand-name drugs with moderate costs. Tier 3 includes non-preferred brand-name medications with higher costs. Tiers 4 and 5, when they exist, cover specialty medications and biologics, which are the most expensive drugs and may require higher out-of-pocket payments.

Generic medications are chemically identical to brand-name drugs but cost significantly less. According to the FDA, generic drugs cost 80 to 85 percent less than their brand-name equivalents. Express Scripts encourages the use of generics to keep overall costs down for insurance plans and patients. If a brand-name medication is on your formulary but a generic alternative exists, you may pay more if you choose the brand-name version.

Express Scripts reviews and updates formularies regularly, sometimes multiple times per year. Medications may be added, removed, or moved between tiers based on clinical evidence, safety data, and cost negotiations with manufacturers. Insurance plans can also customize their formularies, meaning plans from different employers may cover different medications even though both use Express Scripts.

Prior authorization is another tool Express Scripts uses to manage medication coverage. This means a doctor must request permission from Express Scripts before the pharmacy can fill certain prescriptions. Prior authorization applies to some medications because they are expensive, have serious side effects, or should only be used under specific circumstances. The process typically takes one to three business days.

Practical Takeaway: Check your plan's formulary before filling a prescription to understand your costs and whether prior authorization may be needed. This information is usually available on your insurance company's website.

Mail-Order Pharmacy Services and Home Delivery Options

Express Scripts operates one of the largest mail-order pharmacy networks in the country. Mail-order pharmacy is a service that delivers medications to your home, typically for medications you take regularly. Instead of visiting a pharmacy every month, you can receive a 30-day, 60-day, or 90-day supply delivered directly to you.

Mail-order pharmacy through Express Scripts offers several potential advantages. Patients often pay less per dose when ordering larger quantities like 90-day supplies compared to multiple 30-day refills at a retail pharmacy. For example, a medication that costs $30 for a 30-day supply at a retail pharmacy might cost $50 for a 90-day supply through mail-order, which breaks down to about $17 per month. This savings can be significant for people taking multiple medications long-term.

Mail-order prescriptions are typically processed by licensed pharmacists at Express Scripts facilities. These pharmacists review prescriptions for potential drug interactions, check for duplicate medications, and verify that doses are appropriate. The company uses automated systems to package medications safely and accurately. Medications are shipped in climate-controlled packaging to maintain quality during transit.

Specialty pharmacy is another service Express Scripts provides through mail-order. Specialty medications are complex drugs used to treat serious conditions like cancer, rheumatoid arthritis, or hemophilia. These medications often require special handling, storage, or monitoring. Specialty pharmacy services include medication counseling, adherence support, and help managing side effects. Some specialty medications cost thousands of dollars per dose, making these support services important for patients.

Express Scripts also offers pharmacy services integrated with technology platforms. Patients can refill prescriptions online, check refill status, set up automatic refills, and receive medication reminders through mobile apps. These tools are intended to help people take medications as prescribed and avoid missed doses.

Practical Takeaway: If you take the same medications regularly, compare the cost of mail-order versus retail pharmacy at your local store. Mail-order often costs less for longer supply periods.

Cost Management Tools and Understanding Your Out-of-Pocket Costs

Express Scripts offers several tools designed to help patients and insurance plans manage medication costs. Understanding these tools can help you predict what you will pay for prescriptions and find ways to reduce expenses.

Copayments are fixed dollar amounts you pay for each prescription. For example, you might pay $15 for a generic medication, $35 for a preferred brand-name drug, and $60 for a non-preferred medication. Coinsurance is different—instead of paying a fixed amount, you pay a percentage of the medication's cost. For instance, you might pay 20 percent of the drug's price. Some plans use deductibles, meaning you must pay a certain amount out of your own pocket before your insurance starts covering medications.

The medication therapy management (MTM) program is a service Express Scripts offers that may reduce costs for people with multiple chronic conditions. Pharmacists review all medications a patient takes and look for duplications, interactions, or medications that could be stopped. One study published in the Journal of Managed Care Pharmacy found that MTM programs reduced medication costs by an average of $1,500 per patient annually. This service is often available to people who take multiple medications and have chronic conditions like diabetes or heart disease.

Prior authorization can indirectly affect costs because it encourages the use of less expensive, equally effective alternatives before trying more costly medications. When a doctor requests prior authorization for an expensive medication, Express Scripts may approve it but also suggest a lower-cost option. This conversation between doctors and Express Scripts can result in choosing a medication that works just as well but costs less.

Copay assistance programs exist for some brand-name medications. Pharmaceutical manufacturers sometimes offer coupons or patient assistance programs that reduce or eliminate copayments for their drugs. These programs are separate from Express Scripts but can work alongside your insurance coverage. You can search for copay assistance through websites like NeedyMeds.org or by contacting the drug manufacturer directly.

Express Scripts also provides transparency tools that allow patients to compare medication costs before filling prescriptions. Some plans let you check the price of different medications and see cost differences between retail and mail-order pharmacy. Knowing costs in advance helps you make informed decisions with your doctor about treatment options.

Practical Takeaway: Ask your doctor if lower-cost medications can treat your condition just as effectively as more expensive alternatives. Check if patient assistance programs exist for medications you take.

Navigating Issues and Contacting Express Scripts for Support

Questions or problems with your prescription coverage through Express Scripts can be resolved by contacting the company directly