Washington State Rx Services Prescription Benefit Update Elizabeth
Washington State Rx Services: Prescription Benefit Update Elizabeth James, Pharm. D October 16, 2007
Outline § Identify Washington State Rx Services § UMP vs. Aetna Prescription Benefits § Major Changes for 2008 §Q&A
What is Washington State Rx Services? § Prescription drug benefit of two Washington State self-insured products – Uniform Medical Plan (UMP) – Aetna Public Employees Plan of Washington (Aetna) § Administered by the HCA via the partnership of: – The ODS Companies – Med. Impact Healthcare Systems, Inc. – Wellpartner, Inc. – Bio. Scrip
Why? § Senate Bill 5471 directing the HCA to create the prescription drug consortium (WPDP) § In summer 2006, Oregon & Washington together released the RFP for the drug discount card program § In the state of Oregon, The ODS Companies & Med. Impact do not compete for business § UMP joined when its contract with Express Scripts would expire at the end of calendar year 2007, as UMP does not meet exemption criteria
Who Does What for WSRXS? § The ODS Companies – Plan administration – Customer service § Med. Impact Healthcare Systems, Inc. – Network pharmacy management – Prescription drug claims processing § Wellpartner, Inc. – Mail order pharmacy § Bio. Scrip – Specialty drug pharmacy
UMP vs. Aetna Benefit
Retail Pharmacy Benefit UMP § Deductible: $100/person or $300/family § Up to a 90 -day supply § Enrollee cost-share – Tier 1: Lesser of 10% coinsurance or enrollee cost-share limit – Tier 2: Lesser of 30% coinsurance or enrollee cost-share limit – Tier 3: 50% coinsurance (For drugs with a generic equivalent, the enrollee pays the tier 1 coinsurance plus the ancillary charge. Maximum cost-share limit does not apply. Aetna § NO DEDUCTIBLE § 30 -day supply for 1 copay § 90 -day supply for 3 copays § Enrollee cost-share – Tier 1: $10 – Tier 2: $25 – Tier 3: $40 (For drugs with a generic equivalent, the enrollee pays the tier 1 copay plus the ancillary charge)
Mail Order Benefit UMP Aetna § Enrollee cost-share for § NO DEDUCTIBLE up to a 90 -day supply § Enrollee cost-share for – Tier 1: $10 up to a 90 -day supply – Tier 2: $50 – Tier 3: $100 (For drugs with a generic equivalent, the enrollee pays the tier 1 copay plus the ancillary charge) – Tier 1: $20 – Tier 2: $50 – Tier 3: $80 (For drugs with a generic equivalent, the enrollee pays the tier 1 copay plus the ancillary charge)
Specialty Benefit Must Purchase from Bio. Scrip Pre-authorization required Limited to a 30 -day supply Copays same as mail order by tier; ancillary charges apply to some tier 3 specialty drugs § Preferred Specialty Drugs Copay (tier 1) § § – $10 for UMP – $20 for Aetna § Non-Preferred Specialty Drugs Copay (tier 3) – $100 for UMP – $80 for Aetna
UMP vs. Aetna § Otherwise, both plans… – Same cost-share tiers – Same preferred drug list – Same quantity level limits, step therapy programs, and prior authorizations – Same vacation/travel policy – Subject to Washington State Preferred Drug List and Therapeutic Interchange Program
Major Changes to Benefit
Cost Share Tiers § Tier 1: Generic drugs, injectable insulin, & preferred specialty drugs, preferred diabetes supplies § Tier 2: Preferred brand drugs, nonpreferred diabetes supplies § Tier 3: Non-preferred brand drugs, nonpreferred specialty drugs & compounded drugs
Diabetes Supplies § Injectable insulin is covered under Tier-1 § Glucometers – Those in Tier-1 are at no cost to enrollees – All others are covered under Tier-2 § Test strips & lancets covered according to the tier listed on the PDL
Tobacco Cessation Program § OTC nicotine products provided directly to enrollees by Free & Clear – Covered products at no cost to enrollees: lozenges, gum, and patches – Excluded products: nasal spray, oral inhalers § Prescription products will continue to be obtained through the prescription benefit at either the Wellpartner mail order pharmacy or network retail pharmacies at no cost to enrollees
Specialty Drug Program § Bio. Scrip exclusive § Pre-authorization required for most drugs
UMP Vaccine Program § Vaccine services coverage – Beginning in 2008, Uniform Medical Plan will have contracts with retail pharmacies to allow pharmacists to administer vaccines to enrollees – This benefit will NOT be administered through the prescription benefit but through the medical benefit
Minor Changes § § § Some PDL changes New generics available New drugs added to QLL More drugs with Step or PA Some drugs removed from specialty pharmacy Ø Current UMP enrollees affected by these changes will receive notification or be grandfathered to changes
Washington State Rx Services Contacts UMP § Customer Service: (888) 361 -1611 § Wellpartner Mail Order Pharmacy: (800) 417 -8590 § Bio. Scrip: (877) 316 -8921 Aetna § Customer Service: (888) 361 -1612 § Wellpartner Mail Order Pharmacy: (800) 815 -3539 § Bio. Scrip: (877) 316 -8921
Q&A
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