What's Covered and What's Not
Your copay for a particular prescription is based on a list of drugs called a formulary, which sets the copay for that particular prescription based on its inclusion or exclusion in the formulary. For a copy of the formulary, including formulary alternatives, contact Express Scripts.
Covered Expenses
Express Scripts covers:
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contraceptives (including oral, injectable, vaginal, topical and implantable);
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DESI drugs;
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emergency allergic reaction kits;
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emergency contraceptives;
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erectile dysfunction drugs, if used to treat impotency or penile dysfunction and preauthorized;
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glucagon emergency kit;
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injectable prescription drugs purchased at a retail pharmacy or through mail-order as a specialty drug (for some, preauthorization may be required; some injectables may be covered under medical services for a patient at a hospital);
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insulin and diabetic supplies, including
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alcohol swabs;
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blood glucose testing strips;
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injection devices (such as Novopen);
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insulin administered by pen/cartridge or other special injection devices;
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insulin needles and syringes;
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insulin/pre-drawn syringes;
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keytone testing strips;
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lancets;
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lancet devices;
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monitors; and
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urine glucose testing strips;
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legend drugs (i.e., drugs requiring a written prescription unless specified otherwise);
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ostomy supplies;
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prenatal vitamins;
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smoking cessation drugs, inhalers and nasal sprays requiring a prescription (claims for non-prescription nicotine patches are covered through Aetna and reimbursed at network rates—for plan benefits, see "KingCareSM Benefits at a Glance"); and
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topical smoking cessation patches whether prescription or over-the-counter.
Mental Health Prescriptions. Prescription drugs intended to treat any mental health disorder are covered the same as other prescription drugs as the result of the Washington State Mental Health Parity Law.
Expenses Not Covered
The following items are not covered by Express Scripts:
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anorexiants/weight-loss medications;
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any over-the-counter medication unless otherwise noted;
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blood products;
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cosmetic/hair loss medications;
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experimental medications that have not been approved by the FDA;
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infertility medications;
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therapeutic devices or appliances, including hypodermic needles, syringes (except those used for insulin and in the course of administering medical treatment), support garments and other non-medical substances regardless of intended use; and
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vitamins (except prenatal).
In addition to the exclusions or limits described in other sections of this guide, KingCareSM doesn't cover:
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charges that exceed the amounts Express Scripts pays its network pharmacies;
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drugs for a dependent child's maternity care;
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infertility drugs, including Viagra (unless preauthorized);
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non-approved drugs and substances (those the FDA hasn't approved for general use and labeled "Caution—Limited by federal law to investigational use"); and
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sexual dysfunction or transsexualism drugs.
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