Evernorth (formerly Express Scripts) provides pharmacy benefits for each of Duke’s medical plans.
- Website: express-scripts.com
- Toll-free phone: 800-717-6575
Prescription Drug Cover Under Each Plan Offered
Need Help Choosing a Plan?
The Easy Choice Tool is a decision tool which can be used to compare Duke plan options and find the plan that works best for your situation.
| Duke Select Duke Options Duke USA | Duke Advantage | Duke Basic* (frozen) | |
|---|---|---|---|
| Rx Deductible | $100 per person | $3,000 individual $6,000 family (Rx and Medical) | $100 per person |
| Up to a 34-day supply | |||
| Generic | $15 or cost of drug if less | 25% after deductible | $15 or cost of drug if less (deductible applies for Duke Basic) |
| Brand | $50 (deductible applies) | 25% after deductible | $50 (deductible applies) |
| Non-Formulary | $70 (deductible applies) | 25% after deductible | $70 (deductible applies) |
| Up to a 90-day supply at Express Scripts Home Delivery or Duke Pharmacies | |||
| Generic | $25 or cost of drug if less | 25% after deductible | $25 or cost of drug if less (deductible applies for Duke Basic) |
| Brand | $130 | 25% after deductible | $130 (deductible applies for Duke Basic) |
| Non-Formulary | $180 | 25% after deductible | $180 (deductible applies for Duke Basic) |
*The Duke Basic plan will end after 2029 and is only available to current participants.
Making the Most of Your Pharmacy Benefits
Copays and deductibles vary depending on the type of medication prescribed (generic, brand, or non-formulary) the length of the prescriptions, and whether you purchase at a retail pharmacy, through the Evernorth/Express Scripts Home Delivery, or through participating onsite Duke Pharmacies.
After the third fill of a long-term maintenance medication at a retail pharmacy, members are encouraged to fill medications through Evernorth/Express Scripts Home Delivery or Duke Pharmacies. If you continue to purchase a maintenance medication at a retail pharmacy, you will be unable to obtain a 90-day supply and you will be assessed a retail penalty of up to 50% of the cost of the drug (up to $30 for Generic, up to $165 for Brand, and up to $180 for Non-Formulary.)
Generic/Brand
Members are encouraged to use generic medications when a generic substitution is an option. Those who elect to use a brand-name medication when a generic medication is available will pay a higher cost in addition to the brand-name copay. If a generic drug is available but you request to receive the brand-name drug, you will pay the generic copay plus the difference between the cost of the two drugs, regardless of where the prescription is being filled. This applies to prescription drugs purchased at retail, through Duke pharmacies, and through Evernorth/Express Scripts Home Delivery (mail order).
Note: Continuous Glucose Monitors (CGMs) are covered under the Pharmacy benefit. If you have questions about which CGMs are covered, how to obtain a CGM, or the copay that will apply, contact Evernorth/Express Scripts at (800) 717-6575.
Specialty Medications
Specialty medications must be purchased through Accredo® or the Duke Specialty Pharmacy to be eligible for coverage under the plan, unless they are medications which are intended for an immediate need. See the Pharmacy Benefits website for a listing of Specialty medications.
Certain specialty pharmacy drugs are considered non-essential health benefits under the plan, and the cost of these drugs will not be applied toward a member’s out-of-pocket maximum. Although the cost of these eligible specialty drugs will not be applied towards the out-of-pocket maximum, these costs will be reimbursed by the manufacturer at no cost to the member. A list of specialty medications eligible for this program is available online at hr.duke.edu/pharmacy.
Fertility
Injectable fertility drugs are not reimbursed according to Duke’s standard pharmacy benefit. Only plans covering infertility services include coverage of these drugs, which must be prescribed by a Duke Fertility physician for those members residing in North Carolina and require prior authorization through Evernorth/Express Scripts. More information is available at the Infertility Benefits website. The cost of fertility drugs does not accrue to the $25,000 lifetime maximum benefit per member for fertility services.
