Your Prescription Benefit At A Glance

M o n t h Y e a r

About Your Plan

Express Scripts is the company chosen by Client Name to manage your prescription benefit starting <DATE>. We’re here to help you save money
and get the best service on prescriptions for you and your family.

One of the ways we maintain coverage of quality, cost-effective medications is by offering you choices when it comes to getting your medications.
The following chart illustrates your copayments, based on the type of prescription you fill and where you get it filled.

CLIENT NAME PRESCRIPTION DRUG PLAN

Enhanced Intermediate Basic (after deductible is met)

Deductible none none $550 individual $1,100 family

Generic $3 Retail $9 Mail $10 Retail $30 Mail 35%

Formulary Brand $15 Retail $45 Mail $35 Retail $105 Mail 35%
(preferred)
Non-Formulary $50 Retail $150 Mail $50 Retail $150 Mail 50%
(non-preferred)
PPI Coverage Enhanced Intermediate Basic* (after deductible is met)

OTC Prilosec $5 Retail $15 Mail $5 Retail $15 Mail $5 Retail $15 Mail
Generic Omeprazole
and Pantoprazole $25 Retail $75 Mail $25 Retail $75 Mail $25 Retail $75 Mail

Nexium and Prevacid $50 Retail $150 Mail $50 Retail $150 Mail $50 Retail $150 Mail

All Others: Aciphex, Prilosec

40mg and Zegerid $75 Retail $225 Mail $75 Retail $225 Mail $75 Retail $225 Mail

If you choose to purchase a brand name drug when there is a lower-cost generic available, you will be charged the cost difference between the
brand and the generic (up to $100) plus the generic copayment first (subject to plan deductible and copayment if applicable).

07-07053 ©2008 Express Scripts, Inc., All Rights Reserved

 “ a t a g l a n c e ” M ONTH Y EAR

Paying for Your Home

Delivery Prescriptions
Express Scripts accepts most major credit cards and personal checks. The
company safeguards personal and financial information, and provides a
secure website for online transactions.

You have two options when paying for your medications through Home Delivery:
1. Check your copayment amounts through www.Express-Scripts.com and
enclose a check for the right amount.
– or –
2. Have your credit card charged for the full amount of your order.

Drug Updates
Important: Please
Read Carefully
• B rand-name products Lamisil® and Ambien® have been converted
to a non-formulary status.

• B rand-name products Norvasc® and Torpol XL® have been converted

to a non-formulary status. Retail Prescriptions
(30-day supply)
• B rand-name products Cognex® and Coreg® will be converted
to a non-formulary status. Generic Drugs $5
If you’d like to continue recieving a brand-name drug or if there is a medical
Non Formulary Drugs $40
necessity for you to do so, please ask your doctor to write a new prescription,
indicating Dispense As Written (DAW). Otherwise, Express Scripts will automatically
Home Delivery Prescriptions
send you a generic version of your medicatiton once it becomes available.
(90-day supply)
It may take up to 8 weeks for you to start recieving the generic version of the
brand-name drug after the conversion date. Please contact Express Scripts Generic Drugs $10
at XXX-XXX-XXXX to inquire about the converted medication.
Non Formulary Drugs $80

07-07053 ©2008 Express Scripts, Inc., All Rights Reserved