Transcript Document

Final
Conversion to 4D Pharmacy
Management Program for
Prescription Drug Benefit Coverage
under the WMC Self-funded Medical
Benefit Plans for Active Participants
and Retirees pre age 65.
7/20/2015
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Introduction
The Pharmacy Benefit Manager for the Prescription
Drug Coverage under the WMC Self-funded Medical
Benefit Plan will be changed from Express Scripts to
4D Pharmacy Management Company effective
February 1, 2014.
This change in the Prescription Drug Coverage to
the 4D Pharmacy Program only applies to active
participants and early retirees (i.e. retirees under
age 65) who are covered under the WMC Selffunded Medical Plans.
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4D Pharmacy Information
4D Pharmacy is a Michigan based company
located in Detroit’s suburb of Troy.
4D Pharmacy Management Company has been
providing prescription drug benefit
management services for over 25 years.
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4D Pharmacy Information
4D Pharmacy maintains a comprehensive National
retail pharmacy network with over 60,000
participating pharmacies across the US.
Over 2.5 million members are covered by the 4D
Pharmacy Program.
4D Pharmacy has a proven track record of providing
high quality service and cost effective pharmacy
management services.
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4D Retail Pharmacy Network
Pharmacy chains participating under the 4D
Network include:
Meijer
Target
Walmart
Rite-Aid CVS
Walgreens
All of the local retail pharmacies currently
utilized by WMC participants are included under
the 4D Network.
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Reasons for Change to 4D Program
The primary reasons for converting to the 4D
Pharmacy Management Program are:
1. To improve the Overall Service Delivery levels
provided to participants and dependents
under the WMC prescription drug benefit
coverage.
2. To realize immediate cost savings under the
WMC Prescription Drug Coverage by
conversion to 4D Program.
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Service Delivery Improvements
Major service improvements will be provided
under the 4D Program.
A new drug delivery approach is included for
Retail Pharmacy purchase of a 90 day supply of
Maintenance Generic Drugs.
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Service Delivery Improvements
Current mandatory Mail Order requirement for
long-term maintenance Generic Drugs will be
eliminated.
A Voluntary Mail Order Distribution option will
be retained for participants who prefer the
home delivery arrangement.
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Service Delivery Requirements
A mandatory Mail Order requirement will be
maintained under the 4D Program for all longterm maintenance Branded medications
because this is the most cost efficient
distribution method for Branded drugs.
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New 4D Drug Coverage Structure
The current 3 Tier Drug Coverage Structure will
be revised and expanded to a 5 Tiered Structure.
The current MEDTIPSTER Generic Drug Coverage
will be included under the first level or tier of
the 4D Coverage Structure.
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New 4D Drug Coverage Structure
Tier 1 of the 4D Coverage Structure will include:
– The MEDTIPSTER Generic Drug Benefit Coverage;
and,
– A new supplemental coverage for selected Overthe-Counter (OTC) Nonprescription medications,
which are prescribed by the patient’s personal
physician.
There is no copayment for the Generic or OTC
Drugs obtained under the Tier 1 Coverage.
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Tier 1 Drug Coverage
MEDTIPSTER Generic Drug Coverage will cover
the full cost of lower priced Generic prescription
medications, which cost less than $16.00 per
script.
The existing Generic drug coverage provided
under the MEDTIPSTER program will remain
unchanged under the 4D drug plan.
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Tier 1 Drug Coverage
Selected OTC medications, which are prescribed
by your physician (instead of alternate
prescription medications), will be covered under
Tier 1 with no cost to you or your dependents.
OTC medications must be prescribed by your
attending physician in-lieu of other prescription
drug treatments to qualify under the 4D
Coverage.
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OTC Drug Coverage Examples
A separate schedule of all the OTC medications
covered by the 4D Program will be forwarded to
you by February 1st.
Examples are:
Respiratory- Decongestants and Antihistamines.
Cetiriline (Zyrtec/Zyrtec II)
Loratadine (Claritin/Alivert)
Loratadine(Claritin D- 24 hours)
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Tier 2 Under 4D Drug Coverage
Tier 2 of the 4D Coverage Structure will cover All
Other Generic medications, which are included
under the new 4D Drug Formulary Schedule,
except for:
– Low cost Generic Drugs covered under the
MEDTIPSTER Generic Drug Coverage of Tier 1;
and,
– High cost Non-formulary Generic Drugs, which are
not included under Tier 2 of the new 4D Drug
Formulary Schedule
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Tier 2 Drug Coverage
Copayment levels for Formulary/Preferred
Generic Drugs purchased under the Tier 2
Coverage level will depend upon the drug
distribution method and the prescription supply
dispensed.
$15.00 Copayment level for purchase of a 31 day
supply of Formulary Generic Drugs at a
participating 4D Retail Pharmacy.
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Copayment Levels for Tier 2
$30.00 Copayment for purchase of a 90 day
supply of long-term maintenance Formulary
Generic Drugs (i.e. Preferred Generics) at a
participating 4D Retail Pharmacy.
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Copayment Levels for Tier 2
$30.00 Copayment for purchase of a 90 day
supply of long-term maintenance Formulary
Generic Drugs through the voluntary 4D Mail
Order Program.
– There is no change from the current Copayment
level for the Mail Order coverage under the
Express Scripts program.
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Tier 3 Drug Coverage
Tier 3 coverage level will cover all Formulary
Branded Prescription Drugs included under the
4D Drug Formulary Schedule.
The Formulary Branded Drugs are currently
referred to as the Preferred Branded Drugs
under the Express Scripts program.
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Tier 3 Drug Coverage
Copayment levels for Formulary Branded
Prescription Drugs purchased under the Tier 3
Coverage will also be based on the distribution
method and drug supply dispensed under the
prescription.
– A $30.00 Copayment will apply for a 31 day supply
of Formulary Branded Prescription Drugs, which
are purchased at a participating Retail Pharmacy.
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Tier 3 Drug Coverage
The Mail Order distribution method is required
for purchase of a 90 day supply of long-term
maintenance Formulary Branded prescription
drugs under Tier 3 because this is the most cost
efficient delivery approach for these drugs.
A $60.00 Copayment will be charged for
purchase of a 90 day supply of Formulary
Branded Drugs thru the 4D Mail Order program.
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Tier 4 Drug Coverage
Tier 4 coverage under the 4D Drug program will
include– All Non-formulary Branded prescription
medications (i.e. currently Non-preferred Branded
drugs under the Express Scripts program); and,
– All Non-formulary Generic prescription
medications excluded from Tier 2 of the 4D
Formulary Schedule.
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Tier 4 Drug Coverage
Copayment levels for both Non-formulary Generic
and Non-formulary Branded drugs under Tier 4
Coverage will also be based on the drug distribution
method and the drug supply dispensed.
$75. 00 Copayment for purchase of a 31 day supply
of either Non-formulary Generic or Non-formulary
Branded medications thru a Retail Pharmacy.
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Tier 4 Drug Coverage
The Mail Order distribution method is required
for purchase of a 90 day supply of long-term
maintenance Non-formulary Generic or Nonformulary Branded medications under Tier 4
coverage because this is the most cost efficient
approach under the 4D program.
– Mail Order requirement for Non-formulary drugs
is retained from the Express Scripts program.
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Tier 4 Drug Coverage
A $150.00 Copayment will apply for purchase of
a 90 day supply of No-nformulary Generic or Nonformulary Branded medications under the 4D
Mail Order program.
There is no change from the current $150.00
Copayment for Mail Order purchase of Nonformulary (or Non-preferred) medications under
the Express Scripts program.
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Tier 5 Specialty Drug Coverage
A Specialty Drug Coverage provision is being
implemented under the WMC prescription drug
coverage in conjunction with the new 4D
Pharmacy program.
Tier 5 under the 4D program is limited to
Coverage of Specialty Drugs.
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Tier 5 Specialty Drug Coverage
Specialty Drugs are currently covered under the
Preferred and Non-preferred Branded Drug
categories of the Express Scripts program.
The Plan coverage for Specialty Drugs is being
revised under the 4D program.
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Tier 5 Specialty Drug Coverage
Specialty Drugs are a separate class of high
priced medications, which are used for
treatment of severe medical conditions- such as
cancer (chemotherapy), organ transplants,
multiple sclerosis, hemophilia, immune
deficiencies, rheumatoid arthritis, and other
comparable diseases and conditions.
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Tier 5 Specialty Drug Coverage
Specialty Drugs are defined as– Prescription medications, which are used for
treatment of complex and rare medical conditions or
diseases;
– These medications generally require special handling
and/or customized formulation;
– These medications require closer ongoing assessment
and evaluation of treatment results;
– Specialty Drugs are not stocked by retail pharmacies;
– Many Specialty Drugs are customized or designer type
medications, which are significantly more expensive
than other drug treatment programs.
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Tier 5 Specialty Drug Coverage
Participant Copayment level for Specialty Drugs
is 25% of the 4D discounted drug cost with a– Minimum copayment of $75.00 (this is the current
copayment level for Non-formulary or Nonpreferred Branded Drugs); and,
– Maximum monthly copayment level of $500.00
per participant or dependent.
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Tier 5 Specialty Drug Coverage
Specialty Drugs will only be dispensed in a 31 day
supply.
Specialty Drugs can only be obtained thru the
Specialty Drug Pharmacy specified by 4D Pharmacy.
Specialized Mail Order service is the only delivery
method available under the Specialty Drug
Coverage.
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Reasons for Specialty Drug Coverage
Primary Reasons for including a
separate coverage tier for Specialty
Drugs–High Cost of Specialty Drugs
–Customization of Specialty Drug
Treatment Programs for Every
Patient.
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Reasons for Specialty Drug Coverage
Other reasons for including a separate Specialty
Drug coverage• Individual case management and patient
support programs.
• The addition of the Specialty Drug coverage
under the WMC Self-funded Medical Plan
equalizes or balances the drug benefit
coverage between active participants and
retirees.
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Tier 5 Specialty Drug Coverage
Prior Authorization for the Specialty Drug coverage
is required in advance of any treatment
– Prior authorization is currently required for some
Specialty Drugs under the Express Scripts program.
Specialty Drug treatment programs must be
reviewed and approved in advance by 4D clinical
staff to qualify for benefit coverage under the WMC
Plan.
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Prior Authorization Requirement
A Prior Authorization provision is included for specified
prescription medications to ensure safe, effective and
appropriate utilization of these drugs.
The 4D Prior Authorization requirement is comparable to
the existing provision under the current Express Scripts
Program.
This requirement ensures that participants utilize the
selected medications in the most effective manner and it
also supports the cost control of the Plan.
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Prior Authorization Requirement
The specified prescription medications, which
require Prior Authorization:
– May be addictive and subject to overuse, misuse,
and/or abuse;
– Subject to significant safety concerns;
– Sometimes used for other treatments, which are
not covered such as for cosmetic purposes; and/or
– Extremely high cost medications.
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Change in Drug Supply for
Monthly Prescriptions
The 4D Coverage includes a change in the number
of days for which medications are dispensed under
a monthly prescription.
Currently, a 34 day supply of drugs is dispensed for
a monthly prescription under the Express Scripts
program.
The monthly drug supply will be reduced to a 31
day dispensing level under the 4D Program to
conform with drug industry standards.
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Generic Drug Requirement
A Generic Drug Utilization requirement is incorporated under
the 4D program.
This provision requires the front-end utilization of Generic
medications covered under Tiers 1 & 2 at the beginning of a
drug treatment program for new prescriptions.
This requirement supports a continued focus on achieving
higher generic drug utilization levels and reducing costs of the
WMC Plan.
It also minimizes the participant costs as well.
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Step Therapy Requirement
The 4D program also includes a Step Therapy
requirement, which is comparable to the
existing Step Therapy provision under the
Express Scripts program.
The 4D Step Therapy provision integrates with
and complements the Generic Drug
requirement.
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Step Therapy Requirement
The purpose of the Step Therapy requirement is to
initiate new drug treatment programs with the
most commonly accepted and cost effective plan
medications at the beginning of the treatment plan.
Any further progressions to other more costly
Branded medications is based on the inability of the
most common generic drug to provide positive
clinical results for the medical condition.
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Grandfathering for Step Therapy
Most of your existing prescriptions for Branded
medications will be exempted from the application of the
4D Step Therapy requirement during the initial
conversion period.
This grandfathering provision will apply for long-term
maintenance Branded medications which are purchased
thru the 4D Mail Order program (i.e. Well Dyne RX)
during the first 90 days after February 1st.
– Applies for both Formulary and Non-formulary Branded
drugs.
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Grandfathering for Step Therapy
Under this Grandfathering approach, your physician
must notify the 4D clinical staff that your current
prescription for Branded drugs has already met the
prior requirements of the Express Script Step
Therapy provision.
A new prescription from your physician will still be
necessary to obtain refills of Branded drugs thru the
4D Mail Order program under these situations.
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Changes to Drug Formulary
A Drug Formulary is a schedule of approved
prescription medications which can be obtained
under a pharmacy benefit program.
– The schedule also classifies the approved Branded
medications as either Formulary (or Preferred) and
Non-formulary (or Non-preferred) medications based
on multiple factors including cost.
Every pharmacy benefit manager develops and
maintains their own separate Drug Formulary
Schedule.
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Changes to Drug Formulary
There are variations in the classification of some
Branded medications under the Formulary/
Preferred and Non-formulary/Non-preferred
status between the 4D Pharmacy and Express
Scripts Drug Formulary Schedules.
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Changes to Drug Formulary
Copayment levels will be increased for Branded
medications which are considered to be
Preferred Branded drugs under the Express
Scripts Formulary but will now be reclassified as
Non-formulary/Non-preferred Branded drugs
under the 4D Formulary Schedule.
– There are limited number of Branded medications
which will be reclassified as Non-formulary under
the 4D system.
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Changes to Drug Formulary
Copayments will increase from $30 to $75 for
purchase of a 31 day supply of Branded drugs which
are reclassified as Non-formulary (Non-preferred)
under the 4D program.
Copayments will be increased from $60 to $150 for
purchase of a 90 day supply of Branded drugs under
the Mail Order program for the Branded drugs
which are reclassified as Non-formulary (i.e. Nonpreferred) under the 4D program.
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Changes to Drug Formulary
Other lower cost Generic medications or comparable
Formulary (i.e. Preferred) Branded medications are
available as alternate drug treatment programs for most
of these situations.
In addition, the reverse situation will also occur where
some prescriptions currently classified as Non-preferred
Branded medications under the Express Scripts Formulary
will be reclassified as Formulary/Preferred under the 4D
Program.
– Under these circumstances, the drug copayment levels will
be reduced under the 4D program.
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New Prescription Requirements
New physician prescriptions will be necessary
for refill purchases of all long-term maintenance
medications under the 4D Mail Order program
including:
• Maintenance Generic Drugs
• Maintenance Formulary Branded Drugs
• Maintenance Non-formulary Drugs (Generic &
Branded)
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New Prescription Requirements
In addition, for existing prescriptions of
Formulary and Non-formulary Branded
medications, your physician must also notify the
4D clinical staff that the current prescription was
reviewed under and authorized thru the Step
Therapy requirements of the Express Script
program to bypass the 4D Step Therapy
provision.
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New Prescription Requirements
All prescription refills for Specialty Drugs will
also require new physician prescription
authorizations and must be filled thru the 4D
Specialty Drug Pharmacy.
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When New Prescriptions
Are Not Required
The only exception situations where new
physician prescriptions are not required,
includeRefills of existing prescriptions for low cost
Generic Drugs, previously obtained thru a Retail
Pharmacy under the MEDTIPSTER Generic Drug
Program.
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When New Prescriptions
Are Not Required
New prescriptions are not required forRefills of existing prescriptions for Other Generic
Drugs covered under Tier Level 2 of the 4D
coverage, which were previously purchased thru
the same Retail Pharmacy included under the
4D Network.
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When New Prescriptions
Are Not Required
New prescriptions are not required forRefills of existing short-term prescriptions for
Formulary Branded Drugs (i.e. Preferred
Branded), which are covered under Tier Level 3
of 4D Coverage and were previously purchased
through the same Retail Pharmacy included
under the 4D pharmacy network.
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Further Assistance
If you need further assistance, contact:
• Elisa White at PBS 1-800-732-3412, for
service issues or pharmacy benefits coverage
• 4D Member Services 1-877-674-4026, for
questions about specific medications or
formulary substitutes
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