2026 Pharmacy Benefits

What's Changing in 2026?

Plan Design Changes

A number of changes were made across several benefits that, collectively, offset additional increases to the medical plan, including the pharmacy copays on the OAP and CCF medical plans.

Advanced Utilization Management

Beginning January 1, 2026, Dartmouth will adopt Express Scripts' full suite of utilization management.  This means that some medications may now require prior authorization, step therapy or may have updated quantity limits.  Certain drugs may be replaced with lower cost alternatives.  

Eligibility and Enrollment

All benefit eligible employees may enroll themselves and their eligible family members in one of Dartmouth's four Cigna medical plan options.  Pharmacy coverage is included with your Cigna health plan, and is provided by Express Scripts (ESI).  You do not need to enroll in a separate pharmacy plan, as coverage is determined by the medical plan that you choose. 

New Hires may enroll in medical insurance (with pharmacy coverage) within their first 30 days of employment, otherwise existing employees may enroll during the annual open enrollment period held each fall for a January 1st start date.  Some IRS eligible life events causing a drop in external medical insurance will allow for enrollment in a medical plan for yourself and/or your eligible dependents. Life events must be completed in the FlexOnline system within 30 days of the event.

ID Cards

Please allow 7 to 14 days from new hire enrollment for new ID cards to arrive in the mail. You will receive an ID card for each covered member of your family. If you lose your ID card, please contact Express Scripts at the number above, or you may access a copy through the Express Scripts mobile app.

Understanding Your Pharmacy Benefits

Summary of Benefits (SoB)

A Summary of Benefits is a plain language document that outlines the key features, costs, and coverage details of a health insurance plan.

• Open Access Plus (OAP) - 2026
• Cigna Choice Fund (CCF) - 2026
• High Deductible Health Plan (HDHP) - 2026

The National Formulary

The National Formulary is a comprehensive list of approved prescription medications that are covered under your pharmacy plan. The formulary provides a guide for you and your prescriber to help  you choose the most clinically appropriate and cost-effective medications available. It is recommended that you and your prescriber refer to the formulary list when determining which medication is best for you.

Express Scripts has provided tools to help you determine whether or not your medication(s) are covered.

My Medication is no Longer Covered

Formulary medications are continually reviewed and updated based on safety, clinical effectiveness and cost.  The formulary includes both branded and generic drugs.

From time to time, Express Scripts may remove a medication from their Formulary list, and will replace it with a safer and/or more affordable alternative like a generic or biosimilar.  Medications can also change tier level (generic, preferred and non-preferred).  If you are ever affected by a formulary change, you will be notified through US mail, in advance by Express Scripts, and you will be encouraged to have a conversation with your prescriber.  Please take notice of these communications from Express Scripts, Accredo or PillarRx to avoid potential disruption.

Specialty Medications

Specialty Medications are high cost prescription medications used to treat complex or chronic conditions.  They often require special handling and administration and are carefully supervised by health care providers. 

Accredo Specialty Pharmacy - All specialty medications are managed through Accredo and may require you to use mail order for the prescriptions after two refills at your local pharmacy.  Please watch for notifications from Accredo through the  mail or email.  These medications require prior authorizations and often take longer to fill.  Please allow extra time when filling Specialty Medications.

PillarRx Copay Assistance Program - Manufacturer copay assistance is often made available by the drug's manufacturer to provide financial support to patients by covering most or all of the patient out-of pocket costs associated with the high-cost specialty medication.

PillarRx is a consulting firm that works directly with Accredo Specialty Pharmacy to coordinate financial support from prescription drug manufacturers.  The PillarRx care team helps take the burden off the patient by navigating the specialty medication process and negotiating and securing available manufacturer discounts. This program is mandatory and offers members the ability to reduce or remove the co-pay responsibility.  You (or your covered spouse/dependent) will receive a call or letter directly from PillarRx within 60 days of filling your initial specialty medication to start the process.

Participation in the copay assistance program is required to avoid a 30% coinsurance penalty, if you are taking a copay assistance eligible medication.

• • PillarRx Customer Service:  (636) 614-3126
  •  

Important Note - Once the annual value of the copay assistance has been exhausted, PillarRx will work with Accredo to reinstate the benefit coverage at the low to no cost rate.  During this time of transition, you may be asked to pay the full cost of the medication.  If this happens, please reach out to the benefits office and we will work directly with Pillar and Accredo to get this resolved for you.

Advanced Utilization Management

Beginning January 1, 2026, Dartmouth will adopt Express Scripts' full suite of utilization management.  This means that some medications may now require prior authorization, step therapy or may have updated quanity limits.  Certain drugs may be replaced with lower cost alternatives.

Prior Authorization - targets high cost medications and medications with the highest potential for inappropriate use.  Your doctor will need to approve and confirm that the medication prescribed is both appropriate for your condition and cost effective for you.  In these cases, the pharmacy will not fill your prescription until the prior authorization has been approved (typically a 24-48 hour process).

Physician's Prior Authorization Line: 800-417-8164, option 3

Step Therapy - Encourages the trial of one or two lower cost, clinically effective medications before approving the originally prescribed high cost medication.

Drug Quantity Management - Aligns dispensing quantity and treatment frequency with FDA approved dosage guidelines.  This ensures that the most cost effective strength is being dispensed.

Use the Express Scripts Price a Medication tool to see if your medication requires prior authorization, step therapy or drug quantity management.

Costs of Medications

Standard Formulary Medications

Tiered Drug Pricing - Many preferred and non-preferred brand medications have less expensive generic alternatives.  Talk to your doctor to see if there is a generic version of your existing medication and if so, whether it might be a viable option for you.

* If the retail cost of a medication is less than the copay amount, you will pay the lesser amount.

90-Day Prescriptions/ESI Mail Order - When you fill a 90-day maintenance medication through Express Scripts mail order or at a CVS retail pharmacy, you will only be charged the cost of a 60-day fill. Refer to the tiered drug pricing chart shown above. 90-day prescriptions can also be filled through Dick's House pharmacy on campus, but you will pay the equivalent of three 30-day supplies.  90-day fills are not available through other pharmacy locations.

Price a Medication Tool

Express Scripts has provided a tool to help members determine whether a medication is on the formulary and if so, what the cost of that medication (by dosage) would be if purchased through a retail store versus the online Express Scripts Mailorder program.

Express-Scripts.com/Dartmouth

To use the tool, click on the link above, select a medical plan to see what the cost would be if  you were enrolled in that plan and click on the "Price a Medication" button under "$ Compare prices". Enter the name and dosage of the medication. You will also be asked to enter your biological sex* and age* enter your zip code and click on "Get Prices". The tool will display the one and three month costs for both ESI home delivery and across local retail pharmacies.

Pharmacy Coupons

If you are enrolled in Dartmouth's High Deductible Health Plan, you will be required to pay full cost for your medications, until you have met your annual deductible and then you will pay 30% of the cost until you meet your annual out-of-pocket maximum.  It may be worth talking with your pharmacist about using manufacturer coupons to help reduce the out-of-pocket cost on your prescription medications.  NOTE:  Some prescription drug coupons cannot be used in conjunction with Dartmouth's prescription drug plans.  Please check with your pharmacist prio to using a coupon.

Specialty Medications

Specialty medications are high-cost prescription medications used to treat complex or chronic conditions.   When filling a prescription drug through the PillarRx copay assistance program, most or all of your out-of-pocket expenses will be paid by the drug manufacturer. 

NOTE: If you find that the Express Scripts price a medication tool is bringing back a high cost for your specialty medication, it may be worth contacting PillarRx at (636) 317-3126, to see if the medication is eligible for copay assistance under the PillarRx program.

Find a Pharmacy

Express Scripts has a broad retail network of more than 56,000 participating pharmacies nationwide, including:

• Independent pharmacies
• Chain pharmacies such as CVS and Walgreens

Use the Express Scripts Price a Medication Tool to find in-network pharmacies in your local area.

Filling a Prescription

Your Express Scripts (ESI) prescription ID card must be presented when filling a prescription.  Do not use your Cigna medical ID card when filling prescriptions at the pharmacy.

Mail Order Pharmacy - For some maintenance medications, you may find that using Express Scripts Mail Order service for 90-day prescriptions is a more cost-effective way of getting your medications. Use the Express Scripts price a medication tool to compare costs through mail order and retail pharmacies.

Retail Pharmacies - Prescription drugs must be paid for at the time of pickup.  If you pay the full cost of a prescription out of pocket, you will only be reimbursed at the Express Scripts "allowed" amount. Most pharmacies will reimburse the funds if you return within 14 days with your pharmacy ID card and original receipt. Please talk to your pharmacist about your options prior to paying the full out-of-pocket cost. If you have an urgent situation, please contact the benefits office at 603-646-3588. 

Filing a Claim - If you do pay full cost for a prescription, then you will need to submit a claim to Express Scripts, using the Express Scripts Claim Form.

Switching Plans - Whenever possible, we recommend filling a 90-day supply of all important or maintenance medications prior to switching employment or insurance coverage(s).

Create an ESI Account

Setting up an online account with Express Scripts will allow you to:

• Order medications online
• Monitor refills
• Check prior authorizations
• Find additional savings
• and more

• Go to http://www.express-scripts.com/Dartmouth
• Click HOW TO ENROLL at the top
• Click on REGISTER to create your own personal account
  • Family members over age 18 may also create their own personal accounts and manage their own prescriptions.

    Use the Express Scripts Mobile App to store your ID Card, access your medications at a moment's notice, see when refills are needed, and manage your mail order refills.

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Leaving Dartmouth

Your pharmacy benefits end when your medical benefits end.  If you continue your Cigna medical coverage under your COBRA rights, then your pharmacy coverage will also continue.  If you do not continue your Cigna medical coverage under COBRA, then your pharmacy coverage will end on the last day of the month in which you are benefits eligible with Dartmouth.

Transitioning to other coverage

If you take regular maintenance medications, we highly encourage you to fill a 30 to 90 day prescription just prior to your coverage ending here at Dartmouth.  This will allow time for your new coverage to be established before having to request your next refill.

What If I Need a Prescription Prior to Receiving/Returning My COBRA packet?

Prescription drugs must be paid out of pocket and will only be reimbursed at the Express Scripts "allowed" amount. However, most pharmacies will reimburse the overpayment, if you return within 14 days with your pharmacy ID number and original receipt. Please speak with your pharmacy about their process in these cases and what they will allow.  If you have an urgent situation, please contact the benefits office at 603-646-3588.

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