Empire Plan Prescription Drug Flexible Formulary
Frequently Asked Questions
(Prepared by PEF Staff)
Q1: What is the Empire Plan Flexible Formulary?
A: The Empire Plan Flexible Formulary is a list of preferred drugs, classified by therapeutic category or disease, designed to manage prescription costs without affecting the quality of care. A therapeutic category is a group of drugs that treat a specific health condition or that work in a certain way. For example, antibiotics are used for the treatment of infections.
Q2: What is a Formulary “Level” (sometimes called a “Tier”)?
A: Drugs on the Empire Plan Flexible Formulary are grouped into “Levels”, and your copayment is determined by the “Level” that your medication is on.
· Level 1 is your lowest copay choice. It includes all generic drugs.
· Level 2 is your mid-range copay choice and includes preferred brand-name drugs that have been selected as Level 2 drugs because of their overall healthcare value.
· Level 3 is your highest copay choice and includes non-preferred brand-name drugs.
Q3: Who determines which Level a drug will be placed on?
A: UHC’s Pharmacy and Therapeutics (P&T) Committee is composed of both employee and non-employee pharmacists and physicians representing various medical specialties. The P&T committee reviews new and existing medications and places drugs on the Formulary Levels based on each drug's effectiveness, safety, market share, and cost compared with other drugs in the same therapeutic category.
Q4: How is the Empire Plan Prescription Drug Program changing?
A: Effective 1/1/09, the UHC P&T Committee will be permitted flexibility in the administration of the Empire Plan Preferred Drug List. The flexibility will result in the renaming of the Preferred Drug List to the Empire Plan Flexible Formulary and is described below:
· When clinically appropriate and financially advantageous to the Plan, UHC may place a brand-name drug on Level 1;
· Certain therapeutic categories of prescription drugs with two or more clinically sound and therapeutically equivalent Level 1 options may not have a brand name drug in Level 2; and
· Access to one or more drugs in select therapeutic categories may be excluded (not covered) if the drug has no clinical advantage over other generic and brand-name drugs in the same therapeutic category (i.e., drugs that are therapeutically equivalent).
Q5: What does “therapeutically equivalent” mean?
A: Drug products classified as therapeutically equivalent can be substituted with the expectation that the substituted drug will produce the same clinical effect and have the same general safety profile as the prescribed drug.
Q6: What criteria will UHC use to determine if a drug has no clinical advantage over other drugs in the same therapeutic category?
A: Drugs considered to have no clinical advantage that may be excluded from the Empire Plan Flexible Formulary Drug List (and, therefore, not covered) include any products that:
· Contain an active ingredient available in and therapeutically equivalent to another drug covered in that therapeutic category;
· Contain an active ingredient which is a modified version of and therapeutically equivalent to another covered prescription drug; or
· Are available in over-the-counter form or comprised of components that are available in over-the-counter form or equivalent.
Q7: Are brand name drugs used to treat certain medical conditions automatically placed on the Empire Plan Flexible Formulary?
A: Brand name drugs, with no generic equivalents, used to treat HIV/AIDS, cancer and anti-rejection drugs following an organ transplant are always placed on the Empire Plan Flexible Formulary.
Q8: Why is the Flexible Formulary being implemented?
A: The purpose of the Empire Plan Flexible Formulary is to reduce unnecessary costs without impacting clinically appropriate medication options for members and their physicians. This will be accomplished by:
· Excluding coverage for a small number of drugs;
· Placing brand-name drugs on the Empire Plan Flexible Formulary Drug List that provide the best overall healthcare value to the Plan; and
· Applying the highest copayment to non-preferred brand-name drugs that provide no clinical advantage over generic or preferred brand-name drug alternatives.
Certain drugs are being excluded under the Empire Plan Prescription Drug Program so that the Plan can continue to provide the best value in prescription drug coverage to all enrollees under the Plan. Whenever a prescription drug is excluded, generic and/or therapeutically equivalent brand-name drug alternatives will be covered. By excluding coverage for a small number of drugs, the Empire Plan Flexible Formulary discourages the use of expensive "me-too", or copycat, medications that have been found to provide no significant healthcare advantage and yet are priced significantly higher than competing drugs. Me-too drugs are essentially the same as other drugs in their therapeutic category, with a slight chemical modification that allows the manufacturer to have patent protection and continue to price the medication at a much higher cost. For example, Nexium®, and Prevacid® capsules will no longer be covered under the prescription drug program but other lower cost generic and preferred brand-name drugs in the Proton Pump Inhibitor (PPI) category considered to be therapeutically equivalent will still be covered. PPIs are used to treat gastro-intestinal conditions like heartburn and acid reflux.
Q9: Haven’t clinical studies proven that Nexium® is more effective than its predecessor, Prilosec® (omeprazole) as well as other PPIs?
A: There is no evidence proving that Nexium® is more effective than Prilosec® (omeprazole) or other PPIs at comparable doses.
Q10: What is the Instant Rebate Program for PPI users?
A: All enrollees filling a prescription for omeprazole (10, 20, and 40mg strengths) between 1/1/ and 4/30/09 will receive an instant rebate of the applicable generic copay.
Q11: How do I qualify for the instant rebate of the copay for omeprazole?
A: All prescriptions for omeprazole filled between January 1, 2009 and April 30, 2009 will automatically return a zero copayment. You do not have to enroll, or pre-qualify for the zero copayment.
Q12: How will enrollees using one of the medications being excluded from the Flexible Formulary Drug List, or being moved from Level 2 to Level 3, be notified?
A: UHC will mail letters to all enrollees potentially impacted by this disruption. These letters will identify the lower cost, generic and preferred brand-name drug alternatives available to treat the condition.
Q13: When will these letters be mailed?
A: UHC will begin mailing these letters to enrollees’ homes on 11/20/08.
Q14: Is there an appeal process that allows enrollees to obtain benefits for a drug excluded from the Empire Plan Flexible Formulary?
A: No. Drug exclusions and placements of medications on the Empire Plan Flexible Formulary are a component of your Benefit Plan Design and can not be appealed. Benefits will not be provided for a drug excluded from the Empire Plan Flexible Formulary regardless of the reason it is being prescribed.
Q15: What should I do if I am taking one of the medications being excluded from the Empire Flexible Formulary Drug List, or being moved from Level 2 to Level 3?
The Empire Plan Flexible Formulary Drug List allows enrollees and their doctors to choose from a wide variety of prescription drugs. Please talk with your doctor about prescribing a drug that is on the Empire Plan Flexible Formulary. There may be a less expensive Level 1 or Level 2 drug that meets your needs. If a medication is selected that is not on the Empire Plan Flexible Formulary, you will be responsible for the Level 3 copay. If you continue to use a medication that has been excluded from coverage under the Empire Plan Flexible Formulary and benefit plan design, the Empire Plan will provide no benefit and you will be responsible for paying the total retail cost of the drug. Remember, there are clinical therapeutic alternatives available for all drugs excluded from coverage under the Empire Plan Flexible Formulary and plan design. Please discuss these alternatives with your doctor.
Q16: Is there a web site that provides credible, unbiased information on the comparative effectiveness and safety of prescription drugs within the same therapeutic category?
A: Consumer Reports Best Buy Drugs provides consumers with free, easy-to-understand information on drug safety, effectiveness and cost based on the best available scientific evidence, not drug industry hype. Twenty drug categories are currently analyzed at www.CRBestBuyDrugs.org, including high blood pressure, high cholesterol, allergies, coronary-artery disease, heartburn, and depression. The drug reports combine evidence-based research on the comparative effectiveness and safety of prescription drugs with national-level data on drug prices. The information on drug effectiveness is from the Drug Effectiveness Review Project (DERP) at the Oregon Health and Science University Evidence-based Practice Center. The DERP project compiles drug effectiveness data for states to use in shaping prescription drug coverage choices for Medicaid programs. Drug cost information reflects average retail prices paid in cash by consumers at the pharmacy. The reports are peer-reviewed by medical experts in the particular drug category.
Q17: How will my local pharmacist know my drug is excluded?
A: Your local pharmacist will receive a message when your claim is processed which will advise that the drug is not covered under the Empire Plan. If you choose to fill the prescription, you will be responsible for paying the full cost of the drug; the Empire Plan will not reimburse you for any portion of the cost.
Q17: How will my physician know that my drug is excluded?
A: The 2009 Flexible Formulary Drug List will be sent to all participating physicians in the Empire Plan Network. Additionally, if your physician utilizes an online method of prescribing known as E-Prescribing, a message will be displayed indicating that the drug is not covered.
Q18: What will happen if I send a new prescription or request a refill from Medco by Mail for an excluded drug?
A: If you call in a refill of an excluded drug through Medco By Mail, the customer service representative or interactive voice response system will advise you that the drug is excluded, and your order will be cancelled. If you mail in a refill order, you will receive a letter from Medco indicating your drug is no longer covered under the Plan. If you mail in a new prescription for an excluded drug, Medco will return the prescription order along with a letter advising that the drug is excluded from Empire Plan coverage and can no longer be dispensed by Medco By Mail.
Q19: When I enrolled in the Health Care Spending Account (HCSAccount), I calculated my election amount for 2009 based on the amount I currently pay for my prescription drugs. It is now going to be higher (or lower). Can I change my election amount?
A: Members who enrolled in the HCSAccount by the 11/14/08 deadline will have the opportunity to change their election amount. After a member enrolls in the HCSAccount, FBMC, the HCSAccount administrator, will send him or her a letter confirming the amount set aside for 2009. Members who wish to change their election amount, either increase or decrease it, must return their revised confirmation notice to FBMC by 12/10/08. Members who have questions regarding the procedure for changing their election amount should contact FBMC at