Choice Plan - Express Scripts

Express Scripts Medicare’s formularyThe formulary that begins on page 1 provides coverage information about some of the drugs covered byExpress Scripts Medicare. If you have trouble finding your drug in the list, turn to the Index that beginson page 42.The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., NEXIUM ® )and generic drugs are listed in lowercase italics (e.g., omeprazole).The information in the Requirements/Limits column tells you if Express Scripts Medicare has anyspecial requirements for coverage of your drug.Your CostsThe amount you pay for a covered drug will depend on:• Your coverage stage. Express Scripts Medicare has different stages of coverage. In each stage,the amount you pay for a drug may change.• The drug tier for your drug. Each covered drug is in one of four drug tiers. Each tier may havea different copayment or coinsurance amount. The “Drug Tiers” chart below explains what typesof drugs are included in each tier and shows how costs may change with each tier.The Evidence of Coverage (EOC) has more information about the plan’s coverage stages and lists thecopayment and coinsurance amounts for each tier.If you qualify for Extra HelpIf you qualify for Extra Help for your prescription drugs, your copayments and coinsurance may belower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for PeopleWho Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to find out what yourcosts are. You can also contact Customer Service for more information.Drug TiersTier Includes Helpful TipsTier 1:Generic DrugsThis tier includes manycommonly prescribed genericdrugs and may include otherlow-cost drugs.Use Tier 1 drugs for the lowest copayments.Tier 2:PreferredBrand DrugsTier 3:Non-PreferredBrand DrugsTier 4:SpecialtyTier DrugsThis tier includes preferredbrand-name drugs as well assome generic drugs.This tier includesnon-preferred brand-namedrugs as well as some genericdrugs.This tier includes veryhigh-cost drugs.Drugs in this tier will generally have lower copaymentsthan non-preferred drugs.Many non-preferred drugs have lower-costalternatives in Tiers 1 and 2. Ask your doctor ifswitching to a lower-cost generic or preferred branddrug may be right for you.To learn more about medications in this tier, youmay contact a pharmacist at the numbers listed onthe cover of this document.v