Accessing Care
You may receive network benefits or out-of-network benefits, but the level of coverage depends on the pharmacy you use.
Retail Pharmacy Purchases
If an out-of-network provider charges more than the rates Express Scripts pays its network providers, you're responsible for paying the extra amount.
To fill a prescription at a network pharmacy and receive network benefits:
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you must choose an Express Scripts network pharmacy;
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show your Express Scripts prescription card to the network pharmacist each time you fill or refill a prescription (your Aetna medical card isn't valid when you purchase prescription drugs); and
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pay the copay for each covered new prescription or refill. There are no claim forms to submit because the network pharmacy bills the plan directly.
For certain prescription drugs and quantities, your physician will need to obtain preauthorization from Express Scripts.
If you fill a prescription at an out-of-network pharmacy, you must pay the cost of the prescription and submit a claim to Express Scripts for reimbursement. Express Scripts reimburses you at the rate it would pay a network pharmacy, less the appropriate copay. Any amount in excess of this rate is your responsibility.
Mail-Order Purchases
You may purchase maintenance drugs through the mail-order service. "Maintenance drugs" are drugs you must take on an ongoing basis. The first time you use the mail-order service, fill out the patient information questionnaire on the order form available from Express Scripts. This form also includes options for payment. You need to complete this questionnaire only once.
Each time you order a new prescription, you can either:
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send the order form and prescription, together with your payment, directly to the address on the form; or
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have your physician fax the prescription directly from his/her office or call Express Scripts directly.
Once you've submitted the order form, you may obtain refills through the Express Scripts Web site, mail in your refill slip or call Express Scripts. (See Contact Information.)
All prescriptions are processed promptly and usually arrive within 14 days. If you don't receive your medicine within 14 days or if you have questions, contact Express Scripts customer service.
If you use the mail-order service, you pay the 90-day copay amounts even if your prescription is written for less than a 90-day supply. There's no out-of-network mail-order service.
SPECIALTY PHARMACY/CARELOGIC
If you take specialty injectable/biotech prescription drugs, you may fill your specialty prescriptions at a local retail pharmacy one time only. For all subsequent prescriptions of your medication, you'll be directed to fill your prescriptions through CareLogic, Express Scripts' specialty pharmacy. After your first retail fill, CareLogic will send you a letter that details how to have your prescription transferred to CareLogic. If you want to contact CareLogic directly to receive your supply of specialty medication(s), call Express Scripts (See Contact Information):
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Monday through Friday, 8 a.m. to 9 p.m. Eastern Time; or
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Saturday, 9 a.m. to 1 p.m., Eastern Time.
Express Scripts is closed Sundays and holidays, including New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving and Christmas.
A patient care coordinator will contact your doctor and work with you to schedule a delivery time for your medication.
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