Medicare Advantage Pharmacy Benefits
Get started with home delivery
From the Express Scripts Pharmacy to your door
If you're taking a medicine on a long-term basis, using our mail-order service could save you time and money. Standard shipping is free, and a 90-day supply of drugs will usually cost less than buying them at the regular pharmacy. Some prescriptions aren't available by mail order, but millions of people get the medicine they need using this service. Express Scripts will:
Ship your medicine straight to your door
Let you know when it's time to refill your prescription
Call your doctor to change or renew your prescription
You get to:
- Skip a trip to the pharmacy
- Talk to a pharmacist anytime, 24/7, from the privacy of your home
- Get real-time status updates on your prescription orders
- Order refills with just one click
- View your monthly prescription summary online and go paperless
- View your total out-of-pocket drug costs for the year
Starting home delivery is easy. Just go to Express Scripts and register. When you log into your account, you'll be able to quickly fill prescriptions your doctor has sent in electronically, order a refill, check the status of orders, and find savings opportunities. Your account is private and secure.
If you have questions, call 800-820-9729 (TTY: 1.800.716.3231), 24 hours a day, 7 days a week, to talk with a prescription plan specialist at any time. You can also get started with home delivery by using our mobile app or send in orders through the mail.
If you're not taking a long-term medicine now, check back if your doctor prescribes one to maintain your health.
If you're taking a medicine every day over the long term, the Express Scripts Pharmacy is a mail order service that could help you save over retail prices. First time users of mail order service should expect their first order within 14 calendar days after the pharmacy receives an order, however, be sure to ask your prescriber for a 2nd script for short term fill locally to ensure you have enough supply. If your medications do not arrive within 14 days, please call 1-800-820-9729 (TTY:1-800-716-3231) 24 hours a day, 7 days per week.
If member has not used mail order pharmacy in the last 365 days, Express Scripts must obtain member consent for any prescriber-initiated orders, meaning the script was sent to pharmacy on behalf of member via fax, phone, or electronically.
Automatic refill or Automatic renewal services are excluded from Medicare plans. If you have been participating in this program prior to aging into Medicare, you will receive one last fill as you transition and a letter of notification.
A formulary is a list of covered drugs under a Medicare Advantage Part D Plan. The list includes both brand-name and generic drugs. We have a team of doctors and pharmacists—our Pharmacy and Therapeutics Committee (P&T)—who review our lists of covered medications (formularies) for safety and effectiveness. Based on recommendations from our P&T Committee, we occasionally make changes to the medications covered by our formulary.
Medications on the formulary may change for the following reasons:
New medications become available and may be added to the formulary.
Brand-name medications become available as generic. As generic medications become available, the corresponding brand-name medications may be removed from the formulary.
New pharmacy management programs such as prior authorization, step therapy, or quantity limits are adopted for select medications.
In some cases, if you are already taking a medication when its coverage changes, you will be exempt from those changes for the remainder of the plan year. The exception to this exemption is when a generic medication replaces a brand-name medication in the formulary. When that occurs, we'll notify you, in writing, 60 days before the change takes effect. However, the notice period is waived when a medication is removed for safety reasons.
Use these resources to learn more:
- 2017 Medicare HMO Blue ValueRx/FlexRx/PlusRx Formulary
- 2017 Medicare PPO Blue SaverRx/ValueRx/PlusRx Formulary
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. This ensures that our members use these drugs in a safe way. The types of additional requirements are listed below:
Prior authorization (prior approval) – For certain drugs, your doctor or health care provider will need to contact us before you fill your prescription.
Step therapy – For certain drugs, we require you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
To see a complete list of drugs that require prior authorization or step therapy or have dosing limits, view the criteria documents below:
- 2017 Medicare Advantage Prior Authorization Criteria
- 2017 Medicare Advantage Step Therapy Criteria
If a drug you are taking requires prior authorization or step therapy from the Plan, please download and complete the
2017 Request for Medicare Prescription Drug Coverage Determination Form and ask your doctor to fax it to us at 1-617-246-8506.
We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify members who take the drug that it will be removed at least 60 days before the date that the change becomes effective, or at the time the member requests a refill of the drug. The documents below outline upcoming changes to our formulary that may impact you.
If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
If your medication is no longer covered by your Medicare Advantage plan, you have two options:
You can ask Member Service for a list of similar drugs that are covered by your Medicare Advantage plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by your plan.
You can ask your Medicare Advantage plan to make an exception and cover your drug. Contact Member Service at 1-800-200-4255 (TTY: 711), 8:00 a.m. to 8:00 p.m. ET as follows: from February 15 through September 30, Monday through Friday, and from October 1 through February 14, seven days a week, for information about how to request an updated coverage determination or an exception to a coverage determination.