Pharmacy Benefits

Express Scripts, a national pharmacy benefit manager, provides pharmacy benefits for all four medical plans. Co-pays and deductibles vary depending on the type of medicine prescribed (generic, brand or non-formulary), the length of the prescription, and whether you purchase at a retail pharmacy, through the Express Scripts mail order pharmacy, or through participating Duke pharmacies.

New users of some specialty drugs will need their physicians to obtain prior authorization from Express Scripts before prescribing the drugs. A list of these drugs is available here.

Tobacco Cessation

Tobacco users will be charged an extra $20 surcharge per month. This surcharge will be removed if a smoker completes a LIVE FOR LIFE tobacco cessation program. Duke offers a wealth of tobacco cessation support programs and resources to help employees and their dependents break the tobacco habit. Eligible employees enrolled in a LIVE FOR LIFE tobacco cessation program can qualify to receive a free three-month supply of prescription drugs to help them stop smoking.

Duke Basic

Each participant in Duke Basic must satisfy a $100 prescription drug deductible before the plan begins to pay benefits under the co-pay structure described above. For Duke Basic, home delivery is mandatory for maintenance medications. Maintenance medications are those medications that a provider has prescribed for regular (i.e., daily) use, and include (but are not limited to) heart/ulcer/blood pressure medication, hormone therapy, and birth control pills. After three purchases of maintenance medications at a retail pharmacy, home delivery must be used. Some medications prescribed for certain uses must receive authorization before they can be covered.

Co-pay & Deductible Structure for Retail Pharmacies (up to 34-day supply)*

An annual $100 deductible per person applies to short-term brand and non-formulary prescriptions filled at retail pharmacies. This deductible means each person covered by the medical plan must satisfy the $100 deductible for brand and non-formulary drugs purchased at a retail pharmacy before the plan begins to pay benefits under a co-pay structure. There is no deductible for generic drugs (except for Duke Basic*).

The retail co-pay structure for short-term medications and controlled substances is listed below:

  • Generic – $10 or cost of the drug if less than $10 (no deductible)*
  • Brand – $40 (after meeting annual $100 deductible per person)
  • Non-formulary – $55 (after meeting annual $100 deductible per person)

After your third purchase of the same medication, your prescription may be considered to be a long-term medication and you will pay a higher cost if you continue to purchase it at a retail pharmacy (controlled substances and compounded drugs are exempt). Specifically, you will pay 50% of the total cost of the prescription, subject to a minimum and maximum. The minimum is $10 (or cost of drug if less) for generic; $55 for brand; and $65 for non-formulary drugs. The maximum is $25 for generic; $125 for brand; and $135 for non-formulary drugs. You can check with Express Scripts to determine if a drug is on the formulary list.

To avoid paying more for your long-term medications, fill 90-day prescriptions through the Express Scripts Mail Order Pharmacy or participating on-site Duke pharmacies (Duke Clinic, Duke Cancer Center, Duke Children's Health Center, and the Plaza Pharmacy at Duke Raleigh). Duke Children's Health Center Pharmacy has added Saturday hours. Reasons to consider using the mail order pharmacy or participating on-site Duke pharmacies include reduced co-pays and a waiving of the $100 deductible for long-term brand and non-formulary drugs. (See chart below for details.)

Injectable fertility drugs are not reimbursed according to our standard pharmacy benefit, nor are they covered under all of the plans. Only those plans covering infertility services include coverage of these drugs. More information is available here.

Additional information about Duke's pharmacy benefits such as brand-name drugs on the Express Scripts formulary (a list of approved drugs) and frequently asked questions, is available here.

*Participants in the Duke Basic medical plan have an annual $100 deductible for all prescription drugs and are required to use the mail order program or participating on-site Duke pharmacies after the third purchase of a long-term medication.

Co-pay Structure for Express Scripts Mail Order Pharmacy or Participating On-Site Duke Pharmacies (90-day supply)

You will save time and money by filling your recurring, long-term medications through the mail order program or participating on-site Duke pharmacies. Medications through Express Scripts can be home-delivered in a 90-day supply at a discounted co-pay without a deductible.* Your prescription must be written for a 90-day supply because a prescription for less than 90 days will still be charged a 90-day co-payment.

  At a participating retail pharmacy Through the Express Scripts Mail Order Pharmacy or Participating Duke Pharmacies
  Up to a 34-day supply 90-day supply
  First three purchases of any medication After the third purchase of a long-term medication Anytime
Generic
(No deductible)*
$10
(or cost of drug if less)
50%** $20
(or cost of drug if less)
Brand
($100 per person retail deductible applies. No deductible for 90-day deductible supply through mail order or Duke Pharmacies.)*
$40 50%** $100
Non-formulary
($100 per person retail deductible applies. No deductible for 90-day deductible supply through mail order or Duke Pharmacies.)*
$55 50%** $138

*Participants in the Duke Basic medical plan have a $100 deductible for all prescription drugs, including generic and mail-order prescriptions.

**The co-payment (50% of the total cost of the medication) will also be subject to the following minimum and maximum co-payments. The minimum is $10 (or cost of drug if less) for generic; $55 for brand; and $65 for non-formulary drugs. The maximum is $25 for generic, $125 for brand, and $135 for non-formulary drugs. This does not apply to Duke Basic participants, because they are required to use mail order or Duke pharmacies for long-term medications.

Step Therapy

For seven therapies, participants are required to try the generic or target formulary drug (listed below) before the plan will "step up" to pay for alternatives that are more expensive. These therapies are:

  • Osteoporosis
  • Intranasal Steroids (for asthma and allergies)
  • Migraine Therapy
  • Angiotensin Receptor Blockers (for hypertension)
  • Proton Pump Inhibitors (for reflux)
  • Sleep Agents
  • Depression (There is an exception to the step therapy requirement for patients currently on anti-depressants. If you are currently on an anti-depressant, you are not required to change to the generic or target formulary drug.)
Category No Change Required Pre-Certification Required Drugs
Gastrointestinal: Proton Pump Inhibitors omeprazole, pantoprazole, Nexium Aciphex, Kapidex, Prevacid, Prilosec Rx, Protonix, Zegerid
Osteoporosis: Bisphosphonates alendronate, Boniva, Fosamax D Actonel, Actonel w/Ca
Sleep Medications: Hypnotics Generics including zolpidem Ambien CR, Edular, Lunesta, Rozerem
Depression: SSRI's citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline Lexapro, Luvox CR
Hypertension: ARB's Cozaar, Hyzaar, Diovan, Diovan HCT, Micardis, Micardis HCT Atacand, Atacand HCT, Avapro, Avalide, Benicar, Benicar HCT, Teveten, Teveten HCT
Allergy: Intranasal Steroids flunisolide, fluticasone, Nasonex Single-source brands (i.e., Beconase AQ, Nasacort AQ, Rhinocort Aqua, Veramyst, Omnaris)
Migraine: Triptans sumatriptan, Relpax Amerge, Axert, Frova, Maxalt, Maxalt MLT, Zomig, Zomig ZMT, Treximet