Transcript Staff Health Care Committee Power Point

Staff Health Care Committee
Recommendations
An update for UAA’s
APT and Classified Staff Councils
November 2009
Caremark’s
Initial Recommendations
Caremark Recommendation #1:
Copay Changes
Recommendation
What This Means
Increase brand copays
 Generic

Copay would increase by $5 or 25% for
Preferred Brand, and by $15 or 43% for NonPreferred Brand

In 2008, the two tier structure (generic,
brand) became a three tier structure (generic,
preferred brand, non-preferred brand).
For the 2008 standard plan:


Preferred Brand


Keep at $5
Currently $20, increase to $25
Non-preferred Brand

Currently $35, increase to $50

 Generics decreased from $7 to $5
*Mail orders pay 2 copays for a 3 month
supply
 Down $2 or 28%
 Preferred brands increased from $10 to $20
 Up $10 or 100%
 Non-preferred brands increased from $10 to $35
 Up $25 or 250%
Note: These copays could be magnified by other proposed penalties (i.e. the mail order penalty).
Caremark Recommendation #2:
Require Mail Order for Maintenance Meds
Recommendation
What This Means
Incentivized Mail Program
 Maintenance medications
(taken monthly) would be
required to be filled
through the mail order
program after 4, 5, or 6
fills.

After 4, 5, or 6 fills on a maintenance medication
(one taken monthly) at the local retail pharmacy,
the prescription would have to be filled through
mail order.

The “additional copay” would mean that the
patient would pay twice the copay for the drug:

If participants choose to
continue to purchase in the
retail environment, they
would pay an additional
retail copay.
 Add $5 for generic
 Add $20 or $25 for preferred brand [depending on
whether the copay rates change]
 Add $35 or $50 for non-preferred brand [depending
on whether the copay rates change]

This would be a new penalty.
Note: This penalty could be magnified by other proposed penalties (i.e. the “dispense as written”
penalty).
Caremark Recommendation #3:
Dispense As Written Penalty
Recommendation
What This Means
Dispense As Written
 Participants would be
charged an additional
copay for choosing a
brand drug when a
generic equivalent is
available.

If a patient uses a brand drug when a
generic is available, the patient would
pay an additional copay for the drug:
 Add $5 for generic
 Add $20 or $25 for preferred brand
[depending on whether the copay rates
change]
 Add $35 or $50 for non-preferred brand
[depending on whether the copay rates
change]

This would be a new penalty.
Note: This penalty could be magnified by other proposed penalties (i.e. the mail order penalty).
Caremark Recommendation #4:
Performance Step Therapy
Recommendation
What This Means
Performance Step Therapy
 Participants would be
required to use a generic
before a non-preferred
brand is covered.

Participants would be required to try the
generic version of a drug before a nonpreferred brand is covered. The intent is to
ensure there is a reason a member is choosing
to use brand rather than generic.

There is no additional charge associated with
this recommendation, but it could require a
change in the prescription filled from what
was written by the doctor.
Caremark Recommendation #5:
Preferred Brand Optimization
Recommendation
What This Means
Preferred Brand Optimization
 Caremark would reduce
the list of prescriptions
currently on the preferred
brand list, to include only
those with the lowest net
cost, and shortest patent
life (time before a generic
is available).

Some prescriptions currently considered
Preferred Brand would shift to the NonPreferred Brand, which is at a higher copay
level.

Existing prescriptions could be moved to the
higher copay level, which could be magnified
if copay levels are increased or other
penalties are instituted.

This change would affect 1016 participants,
or about a third of the people on prescriptions
in a given month.
Caremark Recommendation #6:
Specialty Guideline Management
Recommendation
What This Means
Specialty Guideline
Management
 A comprehensive,
clinical review of
specialty medication
would be implemented,
evaluating patient
progress to determine
whether appropriate
results were achieved.

Patient progress would be reviewed
for participants currently on
specialty medications.

Specialty medications are a narrow
class of drugs, and very few of us
(about 89 people) are using them.
They treat conditions such as HIV,
Multiple Sclerosis, and Rheumatoid
Arthritis.
Staff Health Care Committee’s
Response to the
Recommendations
SHCC Response:
Principles

Control health care costs while protecting the best interests of the
thousands of staff we represent

Identify reasonable compromises we can stand behind

Respect the doctor/patient relationship

Consider significant mail and weather factors in any changes that
are mandatory
SHCC Response:
Concerns

Raising copays again so soon, particularly to the degree Caremark has
recommended

Implementing too many changes simultaneously. It makes more sense to
select targeted changes and assess the results.

Potential for Caremark’s recommendations to build on each other.


An employee could pay $150 a month to remain on a non-preferred brand of
insulin, purchased at the retail pharmacy to ensure the medicine is not damaged
by sub-zero temperatures or stolen by neighbors. This would be an increase from
$35 now, and $10 paid two years ago.
Punishment for not using the mail order plan, when there are real
concerns about effectiveness, temperatures, and mail problems in
locations where flights have trouble getting in
SHCC Response:
Recommendations

Require patients to try generic before using preferred brand
prescription. Exceptions must be made if there is a medical
reason not to use the generic.

Penalty for using brand when a generic is available is not
necessary, since only patients who have a medical need for the
brand should be using it

Reduced list of preferred brands is not necessary or justified to
affect more than a third of users

Add incentive (not punishment) to increase mail order usage:
50% of retail for first mail order, rather than 66%
SHCC Response:
Recommendations (cont.)

Specialty medication evaluations should be conducted by the
doctor, not the pharmacy vendor

While the committee feels it is too soon for a copay
increase, it is willing to support an increase of $5 for
both the preferred and non-preferred brand medications,
as long as it is NOT accompanied by any
additional penalties for using a brand or not
using the mail order program.
SHCC Response:
Long Term Recommendations

Consider modifying brand copays so the lower tier is for brands
with no available generic and brands where the patient has
documented they cannot take the generic, and the higher tier is
for brands with a generic available and no medical reason why it
is not being used

Human Resources needs to improve communication about the
factors that affect the health care plan costs, and how we can
control them

Increase equality for non-union staff on the Joint Health Care
Committee (who currently have one seat, but make up 60-70%
of employees)
Questions?