1 Prescription Drug Program Summary Express Scripts is one of the most experienced full-service pharmacy benefit management firms (PBM) in the nation. Express Scripts contracts with pharmaceutical manufacturing companies and pharmacies to make sure that we are receiving the most competitive prices and discounts for prescription drugs, helping both the university and our faculty, staff and retirees save on prescription drug costs. Express Scripts has a broad network that includes more than 60,000 pharmacies nationwide, a convenient home-delivery service for easy ordering refills, a full complement of Internet services on the Express-Scripts website, sophisticated drug use checks and balance, a 24-hour-a-day clinical hotline for patients, and well-trained member service representatives. If you are a participant if any of Brown s health care plans for employees, you are covered by the Express-Scripts prescription drug program. You need to use your Express Scripts ID card for all of your prescription drug purchases. Blue Cross/Blue Shield of RI (BCBSRI) and UnitedHealthcare (UHC) are not authorized to service your claims at the pharmacy counter or by mail order. Remember, you will still need to use your BCBSRI or UHC ID to receive all other medical services. If you purchase a prescription from a non-participating pharmacy, you will pay more. You can call Express Scripts Member Services or log on to the Express-Scripts website to find out whether a particular pharmacy is participating. HOW THE PROGRAM WORKS The prescription drug program uses a three-tier copay design. The three-tier design maintains a broad choice of covered drugs for patients and their doctors, while providing an incentive to use medications that are safe, effective and less costly. Frequently, there is more than one prescription drug that your physician could prescribe for a particular illness or condition. Talk with your doctor about your options to determine the best choice for you. The program copays vary by type of drug and whether you fill your prescription at the retail pharmacy or through mail order. Here are the copays: Type of Drug Retail Pharmacy Copay (30-day supply) Mail Order Copay (90-day supply) Generic $6 $12 Formulary/Brand $30 $60 Non-Formulary $45 $90
2 Prescription Drug Types Generic Prescription Drugs. Prescription drugs, whether identified by chemicals, proprietary or non-proprietary name, that are accepted by the FDA as therapeutically effective and interchangeable with drugs having an identical amount of the same active ingredient as their brand name equivalents. Formulary/Brand Name (Preferred) Prescription Drugs. A comprehensive list of preferred brand-name drug products that are covered under the plan. Preferred drugs are selected based on safety, effectiveness and cost. Non-Formulary (Non-Preferred) Prescription Drugs. Prescription drugs that do not appear on the formulary list are considered non-formulary or non-preferred. Formulary Listing A brand-name drug that is on Express Scripts Formulary drug list will save you money compared to a brand-name drug that is not on the formulary list. The formulary list, or preferred drug listing, is a list of recommended prescription medications that is created, reviewed and regularly updated by a team of physicians and pharmacists. The list contains a wide range of brand-name preferred products that have been approved by the FDA. Use of a formulary drug is voluntary; however, your prescription cost will be higher if you doctor does not prescribe a drug on the preferred list. Sometimes your doctor may prescribe a medication for which either a preferred brand-name of generic alternative drug is available. In such cases, your doctor may specify that a prescription be DAW, or dispense as written. The pharmacist may ask your doctor whether an alternative formulary drug might be appropriate for you. If your doctor agrees, your prescription will be filled with the formulary drug. Ask your doctor if you have questions about the change in prescription. Your doctor always makes the final decision on your medication, and you can choose to keep the original prescription. Pharmacies will dispense only the medication authorized by the doctor. Note that in Rhode Island, as in many other states, the pharmacist will automatically dispense a generic if available unless you request the brand-name medication. This is also the process at mail-order. Retail Pharmacy Purchases To locate a participating pharmacy in your home zip code area, call Express Scripts at or visit Express Scripts website at to access the pharmacy directory. When you have your prescription filled at a participating retail pharmacy, remember to present your prescription drug ID card. This card is separate from your medical ID card and provides your pharmacist the required information to accurately process our claim and collect the appropriate copay amount. Presenting your prescription drug ID card at the time of purchase should also alleviate the need for you to complete and submit a claim form directly to Express Scripts.
3 You can initially purchase up to a 30-day supply of a prescription medication from any participating retail pharmacy. It is recommended that you obtain maintenance medications through Express Scripts Pharmacy, which typically offers a better value for a 90-day supply of the same maintenance medications you would obtain at the retail pharmacy. Please refer to the following section labeled Mail Order Purchases for additional details. Mail-Order Purchases Through the Express Scripts Pharmacy, you can order up to a 90-day supply of a prescription maintenance medication as prescribed by your doctor. Prescription maintenance medications are those drugs taken regularly for treating long-term chronic conditions such as asthma, diabetes, hypertension, high cholesterol or arthritis. Typically, a pharmacist at Express Scripts will fill your prescription with a generic drug (if available) unless you specify otherwise. In addition, the pharmacist may contact your doctor if your prescription is unclear or incomplete, or to ask whether a substitution or change may be made to the prescription he/she has written. To order a prescription from the mail-order program, you may obtain an Express Scripts order form from Express Scripts at complete, and mail your order form directly to Express Scripts. You must include your 90-day written prescription (with up to one refill, if appropriate) and applicable copayment amount. For new prescription orders, you will receive your medication within days from the date Express Scripts receives your order. If you need your medication sooner, ask your doctor to write two prescriptions: One for up to a 31-day supply to be filled immediately at a retail pharmacy and paid at the retail copay; and Another that you can send to the mail-order program for an additional 90-day supply at the mail-order copay. Once your medication is down to a 30-day supply, you may order a refill. You will normally receive your refill within business days. Prior Authorization/Coverage Reviews There is a feature of the Express Scripts prescription drug plan known as a prior authorization or coverage review. This review is necessary to determine how the prescription drug plan may cover certain medications. Some medications are not covered unless you receive approval through a coverage review (prior authorization). This review uses plan rules based on FDA-approved prescribing and safety information, clinical guidelines, and uses that are considered reasonable, safe, and effective. During this review, Express Scripts asks your doctor for more information than what is on the prescription before the medication may be covered.
4 Quantity Limits There are times where certain medications will be dispensed with a quantity limit. Additionally, there are instances where there will be limitations on the number of pills dispensed over a period of time. These limits are determined through clinical recommendations and dispensing guidelines. Specialty Prescriptions Express Scripts has a separate network for Specialty medications. The Accredo Recommended Days supply program maintains quantity limitations for certain specialty Prescription Drugs in accordance with FDA approval limits and to help reduce drug waste and prescription drug costs. The first time you submit a claim for a specialty medication on this list, you will be limited to a 30-day supply for four months, even if your physician prescribed a 90-day supply. Your copayment will be prorated, so you will not be penalized for filling the prescription in 30-day supply increments instead of a 90-day supply. An Accredo representative will contact both you and your physician to: Explain why the prescription has been limited to a 30-day supply, Discuss therapy and the disease state, and Discuss the importance of compliance. WHAT S COVERED Generally, Express Scripts covers drugs that require a prescription for dispensing, are medically necessary and are not experimental in nature. Please visit to view the most current preferred drug list (PDL) which will include specific drugs that are covered under the plan. WHAT S NOT COVERED The Express Scripts formulary is updated on a regular basis. This means that drugs may shift from one tier to another or no longer be covered by Express Scripts. Please check the formulary periodically to confirm how your drug(s) is covered under the Express Scripts plan. Except as specifically provided in this booklet, no benefits shall be provided for the following: Over the counter drugs (including topical contraceptives, nicotine products, nutritional products including enteral products and infant formulas, homeopathic products and herbal remedies) DESI Drugs that do not have new FDA approval Contraceptive Devices, example IUD Implantable contraceptives Emergency Contraceptives, Plan B
5 Nutritional Supplements and Combo Nutritional Products Ostomy Supplies Implants by Route and Dosage Forms 3-Month Prepackaged Injectables Cosmetic Drugs Biologicals, Immunizations/Vaccines, Allergy Sera CLAIMS REVIEW AND APPEALS PROCEDURES The Prescription Drug Program has a specific amount of time, by law, to evaluate and respond to benefit claims. These time limits apply to plans subject to ERISA. The period of time permitted to evaluate and respond to a claim begins on the date the claim is first filed. In addition, there are specific timelines and information requirements that you must comply with when filing a claim, or the claim may be denied and the rights you might otherwise have may be forfeited. HOW TO FILE A CLAIM There are two ways to get your Prescription filled when your Doctor places you on a drug therapy for an ongoing condition (i.e., high blood pressure, allergies, and oral contraceptives): 1. Have your doctor fax in the Prescription A doctor s office may fax in a prescription. The mail order pharmacy is not allowed to accept prescriptions faxed in from members. Please ask your doctor s office to fax the prescription to with the following information: Patient s name and cardholder ID number Doctor s name, address, office phone number, and DEA number Time and date Doctor s signature Completed name of the person faxing the prescription 2. Ask your Doctor for two Prescriptions One prescription should be for up to a 31-day supply with no refills that you can take to be filled at a participating retail pharmacy. The second prescription should be for a 90-day supply with refills that you can send in to be filled through the Mail Pharmacy Service. Mail your prescription with the order form to Express Scripts. You may pay by credit card when you send in your prescription, or you may elect to be billed upon receipt of your prescription. Refilling your Prescriptions is easy you can request a refill by: Logging on to (choose For Members ), Calling to use the automated refill system, or Completing the refill form and mail it to Express Scripts Network participating pharmacies typically file claims for you. In rare cases, you will need to pay for the care you receive up-front, then file a claim for reimbursement.
6 To file a claim, you need to complete the Express Scripts claim form and submit it, together with any other information the form requires, to Express Scripts at the following address: Express Scripts, Inc. P.O. Box St. Louis, MO Attn: NGC STD Accts You can request claim forms from Express Scripts or download them from the Express Scripts website at CLAIMS APPEAL PROCESS We will provide at least a first level or initial benefit reconsideration which ensures the benefit or prior authorization criteria were applied correctly. Under ERISA, you may appeal any aspect of a claim including a co-payment/co-insurance, quantity limitation, drug exclusion, prior authorization denial, etc. Appeals relating to non-clinical benefits (e.g., eligibility, co-pay issues, plan exclusions, quantity limits, etc.) are reviewed by the appeals analyst. These benefit appeals are reviewed strictly against the plan design. Appeal determinations for clinical based denials (e.g., diagnosis, prior authorization) are reviewed by the appeals pharmacist. These appeals are reviewed against CORT s approved criteria for the drug based on its approved FDA indicator(s). These appeals are not reviewed for medical necessity. They are reviewed to be sure the criteria were applied correctly and if the information submitted with the appeal would not meet the criteria. The second level appeal is a medical necessity review for denials that are based on diagnosis (e.g., prior authorization). Medical necessity appeals are only for prior authorization (diagnosis based) denials that were upheld in the first appeal. If the appeals pharmacist has denied a clinical appeal, the participant may submit a second appeal for medical necessity. To file an appeal, ask your physician to write a Letter of Medical Necessity. Submit this letter using one of the contact methods below. Mail: Arthur Shinn, PharmD, FASCP Appeals Coordinator Brown University 8590 Vintage Reserve Terrace Lake Worth, FL 33467
7 Secured Fax: Appeal Review Time: Appeal processing time frames are established by ERISA: First level benefit appeals are reviewed within 30 days First level clinical appeals are reviewed within 15 days Second level medical necessity appeals are reviewed within 15 days ERISA also allows for urgent care appeals. Urgent appeals can only be requested for clinical based appeals and can only be requested by your physician. Urgent appeals are reviewed within 72 hours. You will be notified in writing on the appeal decision. If the appeal decision is a denial, you will also be advised of your rights for your next option in the appeals process. ******************
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