Understanding Your Prescription Program. CCIU Employee Meeting September 7, 2016

Transcription

1 Understanding Your Prescription Program CCIU Employee Meeting September 7, 2016

2 Welcome to FutureScripts! Founded in 2006 Philadelphia presence Strong ties to community and local businesses 68,000 pharmacies Integrated with IBC in support of your health! We are your Pharmacy Benefit Management (PBM) partner and we are honored to support IBC in serving the members of CCIU 2

3 Agenda Understanding your Prescription Program Premium Formulary Information and resources Using your Formulary Guide and Lists Tiers of Coverage Prior Authorizations Quantity Limits Drug Exclusions BriovaRx and Specialty Medication Management Home Delivery Looking ahead to

4 Overview Designed to balance pharmacy care and cost. Provides access to affordable medications. Promotes use of preferred brands and lower-cost alternatives for members. Alternative medications are deemed therapeutically equivalent. Only FDA Approved Drugs are covered. Specialty Utilization management programs for Hepatitis C, Rheumatoid Arthritis, Multiple Sclerosis, and Cholesterol (PCSK9 s). Formulary is updated regularly. 4

5 Example Higher-cost brands containing the same active ingredient Leverage exclusion capabilities with manufacturers Drive usage to lower-cost options to treat MS Excluded Preferred $$$ $$ from coverage medications Rebif Extavia Betaseron Avonex Plegridy Multiple Sclerosis Drugs 5

6 Resources From Your Employer: Premium Formulary Guide Premium Formulary Exclusion List Prior Authorization Lists Individualized Letters Specialty Medication FAQ Mail Order FAQ and Forms Online On Line Drug Search: ug_or_pharmacy/formulary/search_drug_list.html Prior Authorization Guidance for Providers 6

7 Resources Speak to a Customer Service Representative See the back of your ID Card for phone numbers 7

8 What to do? Review the Premium Formulary Guide to compare your prescriptions with the listing to determine if all of your prescriptions are on the formulary or if there are special requirements. Tier - Review your prescriptions to determine if they have changed tier under the new formulary which would result in an increased copayment if the RX plan you are enrolled in has copayments. Prior Authorizations (PA s) on certain drugs are required to ensure you are being prescribed the correct drug for your condition. Drugs that may require PAs are drugs that have serious side effects, drugs that should not be combined with other drugs, drugs that may be misused or abuse. Quantity limits are done to protect the individual who is prescribed the drug. Quantity limits may be issued by the FDA or the drug manufacturer. Quantity limits typically reduce the actual number of pills that a pharmacist can dispense. 8

9 Guide Drug Tiers Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or plan sponsor. Discuss these options with your doctor. Tier 1 - Lowest Cost Drug Tier Includes Helpful Tips Tier 2 - Mid-range Cost Tier 3 - Highest Cost Lower-cost, commonly used generic drugs. Some low-cost brands may be included. Many common brand-name drugs, called preferred brands Mostly higher-cost brand drugs, also known as non-preferred brands. Use Tier 1 drugs for the lowest out-of-pocket costs Use Tier 2 drugs, instead of Tier 3, to help reduce your out-ofpocket costs. Many Tier 3 drugs have lowercost options in Tier 1 or 2. Ask your doctor if they could work for you. 9

10 Guide Utilization Management and Safe Prescribing Programs Some medications must be authorized for coverage because they re only approved or effective in treating specific illnesses, they cost more or they may be prescribed for conditions for which safety and effectiveness have not been well-established. Reviewing Medications Our review committee of independent doctors and pharmacists meets regularly to review medications and consider how they should be covered by pharmacy benefit plans. They also recommend prior authorization guidelines. Safe and Effective When making recommendations, the review committee focuses on proven medication safety, effectiveness and cost. The committee considers: U.S. Food and Drug Administration (FDA) approved indications Manufacturer s package labeling instructions Well-accepted and/or published clinical recommendations 10

11 Guide Utilization Management and Safe Prescribing Programs Some medications are noted in your Premium Formulary Guide with letters and symbols referring to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you. Symb ol PA ST QL AR SP GR E Pharmacy Benefit Program Prior Authorization Your doctor is required to provide additional information to determine coverage Step Therapy Trial of lower cost medication(s) is required before a higher-cost medication is covered. Quantity Limits Amount of medication covered per copayment or in a specific time period. Age Restrictions Some restrictions may apply based on patient age. Specialty Medication Medication is designated as a specialty pharmacy drug. Gender Restrictions Some restrictions may apply based on gender. Excluded May be excluded from coverage. Lower-cost options are available and covered. 11

12 Guide Exclusions In addition to reviewing new medications that come to the market, the Pharmacy &Therapeutics (P&T) Committee reviews products for therapeutic equivalency. Evaluations look at active ingredients, indications, and whether products are therapeutically equivalent to alternatives already available on our Formularies. Only once the Clinical review is complete do we begin to evaluate the financial impact of formulary decisions. All recommendations are reviewed by P&T for approval prior to formulary exclusions. We focus on clinically appropriate medications 12

13 Specialty Medications Fourth largest specialty provider 2 state-of-the-art central fill + 17 regional pharmacies Best in class patient-centric model 2.4M total prescriptions 13

14 Specialty Medications provides you with the following services: Working as part of the member s care team with their health care provider Supporting members with counseling and information about their medications Assisting with medication self-administration training Communicating with healthcare providers regarding follow up, as needed Helping members enroll in a Copay Assistance Program, as needed Calling monthly to coordinate the refill shipment of medications Providing 24-hour emergency pharmacy services over the phone 14

15 Specialty Medications Live: Patient Consult via Video Video Consult Checklist Medication & supply review Device assembly (if needed) Injection training Storing procedures Side effects Drug interactions Questions Support & reassurance Copyright FutureScripts. All Rights Reserved. May not be copied or distributed without authorization. 15

16 Future Scripts Home Delivery On October 1, 2016, your prescriptions will be filled from a new FutureScripts mail order facility. Informational letters are being mailed to your home in September. For your convenience, your current prescriptions will be transferred for you including all approved and active prior authorizations. Your personalized Prescription Reorder Form will be provided. It will list transferable prescriptions with refills remaining. Member portal will look slightly different but offer same functionality. Credit card information will need to be re-submitted upon first use. 16

17 Future Scripts Home Delivery To order your drugs from the new facility: Log in to the website on the back of your member identification card (or register if you are a first time user). Transferred prescriptions will appear in the My Prescriptions section under Manage My Prescriptions, and you can place your order from there. On the Prescription Reorder Form, check the box for each prescription you wish to refill and mail your completed reorder form to FutureScripts. 17

18 2017 Updates to formulary and utilization management criteria expected for Watch for the home delivery mailing in early September. Letters will be mailed in early November to advise you of changes affecting your medications. Contact the number on the back of your ID with any questions. Discuss changes with your physician. 18

19 Questions? 19