- Express Scripts Fax Form for Provider
- Medco Pharmacy Express Scripts Mail-Order Form
- Express Scripts Prescription Reimbursement Form
The Diocese of Raleigh prescription drug plan is provided by Express Scripts in conjunction with the medical benefits offered by the Christian Brothers Employee Benefit Trust. Employees and covered dependents must be enrolled in the diocesan medical plan in order to participate in the Prescription Drug Plan. Prescriptions can be obtained through a local pharmacy for short term prescriptions and through Mail-Order for on-going maintenance prescriptions.
Retail co-pay (up to 30-day supply)
Generic - $10
Preferred (formulary) - $35
Non-preferred (non-formulary) - $60
Mail-Order co-pay (90-day supply)
Generic - $25
Preferred (formulary) - $90
Non preferred (non-formulary) - $150
How to Submit
Most providers can file directly. If yours does not, follow these instructions.
To expedite a new mail-order prescription from your healthcare provider, download the mail-order fax form and bring it to your provider. Have the provider complete and fax the form to Express Scripts at 1-800-837-0959.
To mail in a prescription your healthcare provider has already written, download the Medco Pharmacy Mail-Order form and mail the prescription(s) along with the completed form to the address provided on the mail-order form (link above).
The Direct Claim Form may be used for reimbursement only when full price has been paid for a prescription drug order at a pharmacy, when the pharmacy does not accept the prescription drug ID card or if a healthcare ID card has not yet been received.
For additional information regarding the Prescription Drug Plan, log in to Express-Scripts.com or contact Member Services at 1-800-759-1089. You may also obtain information regarding the Prescription Drug Plan through Christian Brothers Employee Benefit Trust at www.myCBS.org/health.