Amerigroup Medicare Member PBM Conversion Talking Points Overview On January 1, 2015, pharmacy benefits for L-Amerigroup Amerivantage (AMV) members will be covered through Express Scripts, Inc. (ESI). When members need to fill prescriptions, they must go to a pharmacy in the Express Scripts network. The pharmacy benefit provides coverage for medically necessary prescription drugs, and some medical supplies that appear in the latest version of the Amerigroup Formulary/Preferred Drug List (PDL). Members can get all prescriptions filled at any Express Scripts network pharmacy. The pharmacy network includes many major chain stores and many independent community pharmacies. Express Scripts will operate as the pharmacy benefit manager (PBM). Important numbers: Member Services: 1-866-805-4589 (TTY 1-800-855-2880) ESI Pharmacy Technical Help Desk: 1-800-281-8172 Amerigroup will no longer handle the prior authorization requests for Medicare Part D. Please contact Express Scripts Prior Authorization Phone number at: Phone: 1-800-338-6180 (TTY: 1-800-899-2114) Prior Authorization Fax: 1-877-526-2307 2015 Coverage Determinations Get Mailed To: Express Scripts Attn: Medicare Reviews P.O. Box 66571 St. Louis, MO 63166-6571 Possible member questions with answers: Q: Have my benefits changed? A: Yes. Please reference the new Amerigroup Formulary/Preferred Drug List or PDL at myamerigroup.com/medicare. Q. Has the formulary changed? A. Yes. Key changes include: WellPoint Medicare affiliates are expanding their network of preferred pharmacies by nearly 50 percent in 2015 for MAPD plans with the addition of CVS, Target, Hannaford Brothers, Food Lion, Giant Eagle and Harris Teeter Supermarkets to the current Wal-Mart and Kroger companies. Members can save at least $5 per prescription by using a preferred network pharmacy. WellPoint affiliated MAPD plans have added a select care tier to their formularies this year that includes certain generics for hypertension, cholesterol and diabetes. Drugs on the select care tier are
available for $0 or low copay. The purpose is to encourage members with these conditions, which are common in older adults, to stay healthy by following their treatment regimes. WellPoint MAPD plans do not include a select care tier, but all of these same drugs are available for $1 copay at preferred network pharmacies. WellPoint affiliates have eliminated the injectable tier from the formularies of their MAPD plans in 2015, incorporating injectables into the regular tiers to better align with competitors. This change is not expected to increase member cost shares. In fact, depending on the particular plan, these drugs may actually cost less than 2014 for some members. Prescription drug benefits for about 50,000 Amerigroup Medicare members will be managed by Express Scripts in 2015 to better coordinate administration. Express Scripts has provided pharmacy benefits management services to WellPoint and its affiliates since 2010. Q: Why are medications placed on certain tiers? A: Drugs are placed on certain drug tiers or levels, depending upon what type of drug it is (generic vs. brand medication) and price. Each tier is assigned a specific copay or coinsurance determined in the benefit as the member s responsibility. A Pharmacy & Therapeutics (P&T) committee made up of doctors, pharmacists and other health care professionals makes tiering and other clinical decisions for our formulary. Q: Where can I find a list of your 2015 formularies? A: The lists of formularies for both our Medicare Advantage Prescription Drug Plans and our standalone Prescription Drug Plans will be posted on myamerigroup.com/medicare website, effective Oct. 1. The lists are searchable by drug name. Q: Why would my medications no longer be covered/removed from the list of covered drugs (formulary) for a new plan year? A: Drug lists are reviewed and updated every year to reflect changes in drug prices, safety issues, less expensive alternatives, etc. It is our goal to minimize drug list changes, while providing cost-effective, clinically sound medications for our members. Q: What alternatives do I have if my medication is no longer covered? A: Members are notified early so they can compare formularies for different plans. Additionally, they can call the customer service number on the back of their member ID card for a list of similar drugs that are covered by the plan. To allow members time to speak to their doctor about alternatives, members may fill a temporary supply of their prescription during the first 90 days of the year. Members in a long-term care facility can get at least a 31-day supply, or, if needed, at least a 91- to 98-day supply, depending on the prescription dispensing increment (unless the prescription is written for less). Also, if needed, they may get additional refills during the first 90 days of the year. Members not in a long-term care facility may receive a one-time, 30-day fill at a network pharmacy (unless the prescription is written for less). Providers may ask for a formulary exception when they feel formulary options are not right for their patient. To file an exception request for 2015, a doctor, or other prescriber, will need to explain the medical reasons why his or her patient needs the exception approved. The doctor or other prescriber can tell us by phone and follow up by faxing or mailing a signed statement any time after December 1, 2014. They can contact us at the following: The toll-free physician phone number is 1-800-338-6180. The toll-free fax number is 1-877-526-2307.
If mailing, the address is as follows: Express Scripts Inc. Attn: Medicare Reviews P.O. Box 66571 St. Louis, MO 63166-6571 Q: Why did you increase my copay/change the tier of my medication? A: Occasionally, we move a drug off the formulary or up a tier as a generic is released or a new drug has come to market. We evaluate our copays annually to determine if changes are needed, as the manufacturer may also change the price of the drug. In 2015, copays may be higher or lower depending on the drug. Q: Why did you decrease my copay/change the tier of my medication? A: Occasionally, we move a drug to a better tier position as a result of new clinical information that shows it delivers better clinical outcomes than other drugs in the class. Other times, if the price has dropped significantly without compromising clinical quality, we move it to a lower tier. We evaluate our copays annually to determine if changes are needed. In 2015, copays may be higher or lower depending on the drug. Q: How is your drug tiering determined? A: A group of non-wellpoint doctors, pharmacists and other health professionals meet with our own doctors and pharmacists to determine which drugs are safe, effective and widely used to treat conditions specific to our members needs. This group is called the Pharmacy and Therapeutics (P&T) Committee. The P&T Committee reviews scientific evidence and drug pricing information to make a final drug coverage and tiering decision. Q: What are quantity limits? A: Quantity limits regulate the amount of medication covered by a plan for a certain length of time. Quantity limits are put in place to ensure that the drug is used per the prescribing information; this assists with patient safety and also avoiding waste and / or abuse potential. Q: What is step therapy? A: Step therapy requires members to try one drug before trying another. This ensures members try a preferred agent before a non-preferred agent, thus helping members try lower-cost options before higher-cost options. The step-through drugs are reviewed by the P&T committee to be clinically appropriate drugs. At the point of sale, if the member s history is in the system, the member s drug history will be screened automatically to determine if they have met the criteria. Q: What is prior authorization? A: To ensure appropriate use, certain drugs require prior approval from the plan before a prescription can be filled. For example, many drugs are used off-label for purposes not specifically approved by the FDA. While we do cover many of these uses, we need to confirm that the use is appropriate, based on published literature. If the authorization is granted, the prescription will be filled. If not, an alternative drug may be required. Q: Why would another MAPD have the same drug on a lower cost sharing tier/available for a lower copay/coinsurance? A: CMS gives plan sponsors the flexibility to design their formularies within a certain set of guidelines. Because each sponsor negotiates with various drug companies, drug pricing may vary from plan to plan and from year to year. For example, if we are able to negotiate better prices on one or two specific drugs in a category that are
of equivalent effectiveness to other drugs in the category, we can provide coverage for that drug(s) at a lower price, allowing our members to pay a lower copay. When reviewing a formulary, it is best to consider all of your drugs rather than a few individual drugs. Q: How often do you make changes to covered drugs? A: Generally, we will not discontinue or reduce coverage of a drug throughout a plan year unless a new, less expensive generic drug becomes available or new, or adverse information about the safety or effectiveness of a drug is released. Q: Could you remove my drug from the formulary during the year, and if so, how will you communicate this change to me? A: Generally, the formularies are set for the year. However, we might make changes if there is a safety issue or if a lower-cost drug becomes available. If we make changes during the year, we will contact affected members at least 60 days before the change becomes effective unless the drug is deemed unsafe or removed from the market. Q. Why does WellPoint require an exclusive provider for insulin and supplies? A. With so many suppliers and so much advertising, the cost of diabetic supplies, including insulin, was spiraling out of control and abuses were common in the industry. WellPoint negotiated with exclusive providers to keep the cost of diabetic supplies affordable while ensuring quality. WellPoint will maintain an insulin exclusivity contract with Eli Lilly, the manufacturer of Humulin and Humalog human insulins. Novolin and Novolog insulin and most other insulins are not eligible for coverage. Lantus insulin, however, will continue to be covered under this agreement. LifeScan Inc. (OneTouch ) and Roche Diagnostics (ACCU-CHECK ) are exclusive providers of test strips and glucometers. Supplies will not be covered for those who use another provider without an exception being granted. Additionally, supplies can only be purchased through a pharmacy and not a DME (durable medical equipment) provider. Q. Why is Rite-Aid no longer included on your list of preferred pharmacies? A. We were unable to negotiate the same rates with Rite-Aid as we were with other preferred pharmacies for 2015. As a result, Rite-Aid will no longer be in our preferred network, but remains part of our Medicare pharmacy network with standard cost-sharing. Even without Rite-Aid, our preferred pharmacy network includes 16,664 locations. Q. Why are you moving management of Amerigroup s drug program to Express Scripts? What impact will it have on members? A. Prescription drug benefits for about 50,000 Amerigroup Medicare members will be managed by Express Scripts in 2015 to better coordinate administration. Express Scripts has provided pharmacy benefits management services to WellPoint and its affiliates since 2010. The Express Scripts network includes 68,000 pharmacies with more than 4,800 drugs. The transition is expected to be mostly seamless to members. However, just as is the case with every new benefit year, some members may need to change their pharmacy, mail-order or drug options. Q. Do people getting Extra Help or those with a SNP plan have to pay higher costs if they don t use a preferred pharmacy? A. No. Those Medicare beneficiaries receiving Extra Help from Medicare have defined benefits that are determined by the Center for Medicare & Medicaid (CMS). Those benefits will not change based upon which
retail network pharmacy the member uses. However, if the cost-sharing is lower at a preferred network pharmacy than the CMS defined benefits for those receiving Extra Help, the member will get the lowest copay available when using a preferred network pharmacy. Q: Can I go to the same drugstore I ve gone to before? A: You can get prescriptions filled at any Express Scripts network drugstore. The drugstore network has many brand-name stores and community pharmacies. Call Member Services for a provider directory or go online to myamerigroup.com/medicare. If you don t know if a drugstore is in the network, ask the pharmacist. You can also call Member Services toll free at 1-866-805-4589 7 days a week from 8 a.m. to 8 p.m. If you are deaf or hard of hearing, call the AT&T Relay Service toll free at 1-800-855-2880. Q: Where do I call if I have questions about my drug benefits, copays, etc.? A: Call Amerigroup Member Services toll free at 1-866-805-4589 7 days a week from 8 a.m. to 8 p.m. If you are deaf or hard of hearing, call the AT&T Relay Service toll free at 1-800-855-2880. Q: Where can members and providers find the Amerigroup formulary? A: Members and providers can find the formulary online at myamerigroup.com/medicare. If you need more help, please call Member Services at 1-866-805-4589 7 days a week from 8 a.m. to 8 p.m. If you are deaf or hard of hearing, call the AT&T Relay Service toll free at 1-800-855-2880. Q: Is there a website I can visit to see my drug benefits? A: You can go online to www.myamerigroup.com/medicare. If you need more help, please call Member Services at 1-866-805-4589 7 days a week from 8 a.m. to 8 p.m. Eastern time. If you are deaf or hard of hearing, call the AT&T Relay Service toll free at 1-800-855-2880. Q: Will over-the-counter (OTC) medicines be covered? A: No. Q: Do I have to use a specialty drugstore to fill my prescription for specialty drug(s)? A: No.