Benefits Plans - Prescription Drug Plan: Prescription Drug Plan Newsletter

Page last updated: Wednesday, 26-May-2010 20:51:14 EDT

Summer 2004

Printable Newsletter

Click the link below to download a printable version of the newsletter.
Summer 2004 Prescription Drug Plan Newsletter (PDF)

Contents

  1. Prescription Drug Plan Cost and Savings
  2. Benefit Innovation Award
  3. Travel "Vacation Override"
  4. AdvanceRx "Rush" Delivery $15
  5. Prior Authorization (PA)
  6. PPI Prior Authorization at 120 Days
  7. Reimbursement for Non-Network Claims
  8. New Drug Releases and Prior Authorizations
  9. Lost Your AdvancePCS ID Card?
  10. Diabetic Insulin and Supplies Clarification
  11. COX-2s (Celebrex, Vioxx, and Bextra) Step Therapy to begin October 1, 2004
  12. What You Can Do to Save

1. Prescription Drug Plan Cost and Savings

Despite Department of Health and Human Services projections that prescription drug costs would increase by 13.4 percent in 2003, the rate of increase at U-M was only 2.8 percent, due to the U-M’s new prescription drug program. In its first full year of operation, the program produced savings of $8.6 million.

The plan design was effective at producing additional savings through the increased use of generics and more cost-effective brands, the availability of the mail-order pharmacy and an increase in drugs available over-the-counter (OTC). The reduction in total cost of the plan helps mitigate the impact of future premium increases for the University and plan participants. Below are several facts on the 2003 drug plan:

U-M Rx Facts for 2003

Number of prescriptions dispensed

858,059

Average number of prescriptions filled for employees

8.4

Average number of prescriptions filled for retirees

25.49

Average total cost per claim

$61.98

Average brand-name drug cost

$95.00

Average generic drug cost

$23.62

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2. Benefit Innovation Award

The University of Michigan was one of three organizations presented with the Rx Benefit Innovation Award recognizing creative approaches to drug benefit program management. The Pharmacy Benefit Management Institute (PBMI) presented the awards on April 29 during PBMI’s annual drug utilization management conference in Scottsdale, Arizona. PBMI is an independent organization providing research-based education for the design and management of pharmacy benefit programs.

U-M was recognized for demonstrating the value of consolidating drug benefit management services across all health plans and utilizing internal clinical resources for drug benefit management. All of the organizations being honored focused on the critical drivers behind rising prescription drug expenditures and took action to change behaviors and reduce costs, said PBMI Founder and President Michael H. Deskin. “The efforts of these organizations to reduce the growth in prescription drug expenditures ensures the right people get the right drugs when needed,” said Deskin.

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3. Travel "Vacation Override"

Need an extra month of your prescription to take on vacation? Call AdvancePCS member services 1-866-485-0268 before going to the pharmacy. The AdvancePCS representative can arrange a vacation override. With the override your pharmacist will be allowed to dispense a supply greater than a 34-day supply. You will be charged two co-pays for up to a 68-day supply of medication. You may request up to two vacation overrides in one calendar year.

If your travel outside the USA requires more than one extra month of prescriptions, please call the U-M Benefits Office for an overseas travel override.

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4. AdvanceRx "Rush" Delivery $15

AdvanceRx Mail Order Service can provide next-day delivery upon request for an extra shipping fee of $15. There is no shipping charge for First Class U.S. Postal Service delivery (4-7 days).

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5. Prior Authorization (PA)

There are several drug classifications that require Prior Authorization (PA). These drugs are on the PA list due to safety and cost concerns. The plan requires that use of the drug meets clinical criteria and follows acceptable, evidence-based treatment guidelines. If your drug requires a PA, your physician must call AdvancePCS at 1-800-294-5979 before the medication can be approved. See Prior Authorization for the the list of drugs requiring prior authorization.

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6. PPI Prior Authorization at 120 Days

Members on any PPI drug (Aciphex, Nexium, omeprazole, Prevacid, or Prilosec) should be aware that after 120 days of PPI use per calendar year, further supplies must be approved by AdvancePCS. The member’s physician should call AdvancePCS at 1-800-294-5979 for a prior authorization each year. FDA guidelines, for most indications, approve use of PPI therapy for short-term therapy use only; thereafter the member must demonstrate they meet clinical guidelines for continued therapy. Physicians will discuss with AdvancePCS the patient status and need for continued PPI therapy. Use of an H2 receptor antagonist, such as ranitidine, may provide adequate therapy and would not be subject to this restriction. Members can discuss this as an option with their physicians, as it is not appropriate for everyone.

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7. Reimbursement for Non-Network Claims

The University strongly encourages you to present and use your AdvancePCS prescription coverage card at a participating Network pharmacy.

AdvancePCS, a Caremark company, provides a network of over 51,000 participating pharmacies in the U.S., over 2,100 located in Michigan. AdvancePCS has negotiated aggressive, specific contract rates of reimbursement with Network pharmacies.

If you have your prescription filled at a pharmacy that does not participate with AdvancePCS, you will have to pay the full cost of the drug and file a claim for reimbursement. Reimbursement for prescriptions paid at full cost, regardless of the pharmacy, will be reimbursed only at the contracted price that a participating Network pharmacy would have charged for the same drug, minus your co-insurance or co-pay amount.

For example, if you purchased fluoxetine 20mg 30 capsules (generic Prozac) from a non-participating pharmacy for $33.99, your reimbursement would only be the Network contracted rate of $10.45 minus your co-insurance or co-pay.

  • If your co-insurance is 20%, your reimbursement would be $8.36 (80% of $10.45). By using a non-Network pharmacy, or failing to present your AdvancePCS prescription card to a Network pharmacy, you paid $25.63 too much.
  • If your co-pay is $7.00, your reimbursement would be $3.45 ($10.45-$7.00 co-pay). By using a non-Network pharmacy, or failing to present your AdvancePCS prescription card to a Network pharmacy, you paid $30.54 too much.

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8. New Drug Releases and Prior Authorizations

See Drug Reviews for a list of drugs that were reviewed and determined for formulary inclusion and tier placement by the U-M Pharmaceutical Benefits Advisory Committee in January through March 2004.

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9. Lost Your AdvancePCS ID Card?

Please call the HR/Payroll Service Center at 734-615-2000 locally, or 1-866-647-7657 toll free within the U.S. for a replacement.

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10. Diabetic Insulin and Supplies Clarification

Diabetic Insulin, Needles and Syringes are available to all participants in the University of Michigan prescription drug plan at a zero ($0) co-pay when the AdvancePCS prescription drug ID card is used at a network retail pharmacy, or from the AdvanceRx.com mail order pharmacy.

Coverage of diabetic supplies (injection devices, alcohol swabs, testing strips, lancets, and blood glucose testing monitors) is determined by your medical insurance plan participation as described below.

Comprehensive Major Medical (CMM) Participants
Diabetic supplies are covered for Comprehensive Major Medical (CMM) participants only with a zero ($0) co-pay when the AdvancePCS prescription drug ID card is used at a network retail pharmacy, or from the AdvanceRx.com mail order pharmacy.

Participants in All Other Medical Insurance Plans
For all other participants in the University of Michigan prescription drug plan, diabetic supplies are available at a zero ($0) co-pay only when the medical insurance ID card is used at an authorized Durable Medical Equipment (DME) provider. Contact your medical insurance plan administrator (M-CARE, Care Choices, Health Alliance Plan, or Blue Cross Blue Shield of Michigan) for further instructions on how to obtain diabetic supplies through your medical plan’s DME suppliers.

Reimbursement Claims for Diabetic Supplies and Equipment
For diabetic supplies purchased out-of-pocket and then submitted for reimbursement, the refund may be reduced to the price contracted with authorized DME providers. Submit claim forms to your medical plan (only CMM members can use AdvancePCS claim forms for diabetic supplies). Participants in BCBSM/United of Omaha who submit diabetic supplies receipts to United of Omaha will be limited to the standard 80% reimbursement after the annual deductible is met.

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11. COX-2s (Celebrex, Vioxx, and Bextra Step Therapy to begin October 1, 2004

Step Therapy is a tool that can be used for certain drug categories to help ensure member safety and appropriate use while managing cost. It is a ‘step’ approach to providing drug treatment. Step Therapy recommendations are reviewed by a committee of physicians and pharmacists to ensure safe, effective drug therapy. Step Therapy may require the member to use a “first-line” drug before authorization is granted for a more costly “second-line” drug.

COX-2s are generally considered second-line therapy for pain management, and are generally used for arthritis. Currently, the COX-2s include brand name products Celebrex®, Vioxx®, and Bextra®.

Because this Step Therapy impacts very few drugs, you most likely will NOT be affected by this change. Only members under the age of 60, and beginning new COX-2 therapy may be affected. More information will be available on the Benefits Office Web site in the near future.

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12. What You Can Do to Save

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Limitations
The University of Michigan in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents. Although the university has elected to provide these benefits this year, no individual has a vested right to any of the benefits provided. Nothing in these materials gives any individual the right to continued benefits beyond the time the university modifies, amends, or terminates the benefit. Anyone seeking or accepting any of the benefits provided will be deemed to have accepted the terms of the benefits programs and the university's right to modify, amend or terminate them.