In 2014, significant changes are being made to the prescription drug benefit administered by Express Scripts for the Welfare Fund, changes that will allow the Fund to continue to offer an affordable and reliable drug program, while helping you maintain your health and also reducing your out-of-pocket costs.
Be aware that most changes concern prescriptions for long-term, maintenance medications, not the occasional treatment of acute illness.
Formulary Changes
As the Fund’s pharmacy benefit manager, Express Scripts negotiates with drug manufacturers to provide the most cost-effective package available. This can lead to medications being dropped from the “formulary” – the list of medications covered by our Fund. When a drug is dropped, Express Scripts will offer one that is clinically equivalent and will inform doctors of the change. A prescription for medication dropped from the formulary can be filled if a member chooses to pay the full cost, but the Welfare Fund does not recommend this: your doctor should be able to find an equivalent medication on the formulary at a lower cost to you.
Within the formulary there is a distinction between “preferred” and “non-preferred” medications. The difference may affect the amount of your co-payment, but only at “lower” costs. There is a 20% co-payment with a minimum of $15 for a 30-day supply of a preferred drug and a 20% co-payment with a minimum of $30 for a 30-day supply of a non-preferred drug. If a preferred drug and a non-preferred drug each cost $50, the former would have a co-pay of $15 and the latter would have a co-pay of $30. However, if a preferred drug and a non-preferred drug each cost $400, each would have the same $80 co-pay.
Express Scripts has sent a targeted letter to every current user of a medication that will be changing status or coming off the formulary completely. Adequate time will be provided to adjust to any necessary changes.
Lifting the Cap
The Affordable Care Act (ACA) prohibits health plans such as ours from imposing annual or lifetime dollar maximums on essential benefits. As of July 1, the Welfare Fund’s $10,000 annual limit on drug coverage for active (employed) members will be removed. Now, instead of a member paying the entire cost of a prescription after the $10,000 level, the co-pay will be 50%. If a member’s annual drug spending by the Fund reaches $15,000, the co-pay will become 80%. Given the Welfare Fund’s financial limits, it is not possible to both remove the cap and maintain the customary 20% co-pay at the higher spend level without putting the entire program at risk.
Other measures the Fund trustees are taking to assure the best use of resources include the introduction of “prior authorization” and “step therapy” (see below).
Prior Authorization
This program involves a review of a few, select medications before dispensing, to ensure proper application and dosage. Express Scripts will notify you if and when a medication requires approval. If so, your doctor will need to contact Express Scripts before the prescription is filled again. You will be responsible for the full cost of the medication unless your doctor gets approval. Once prior approval is granted, you are responsible only for the relevant co-pay.
Step Therapy
This program asks you to use a lower-cost, clinical equivalent to the medication you have been taking. Express Scripts will notify you of alternatives and ask you to share this information with your doctor. If you and your doctor agree that the alternatives are not right for you, your doctor may request a coverage review. When appropriate, your doctor can request an override, allowing you to take the current medication without penalty.
The Fund is aware that the formulary changes, as well as the prior authorization and step therapy programs, can be inconvenient at the start, but these programs are essential to the Fund’s ongoing efforts to maintain an affordable and reliable prescription drug benefit for you and your family.
More detailed information, contained in a letter sent to all Fund participants, is online.
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