RMIP Prescription Plan FAQ's

Transcription

1 RMIP Prescription Plan FAQ's A new U.S. Pharmacy Benefit Manager has been selected for January 1, CVS/caremark. 1) Why is the RMIP changing to CVS/caremark? The Express Scripts contract ends on December 31, The pharmaceutical industry is very dynamic and it is important that the Bank review the pharmaceutical administration services available to MIP members on a regular basis through a process of competitive bidding. As a result of competitive bidding following the Bank s procurement process, CVS/caremark was chosen to provide these services to the Bank. 2) How was CVS/caremark selected? The World Bank s procurement process was followed. An independent pharmacy consultant assisted in the bidding process and evaluation of the proposals. Representatives from the business, including the Staff Association and the 1818 Society, participated in the selection committee. 3) Why is CVS/caremark making me pay for my Generic medications? CVS/caremark is not responsible for this change. They administer the benefits offered by the MIP and RMIP. After a process of comprehensive internal and external consultation, it has been agreed that the MIP and RMIP will introduce a 10% coinsurance on Generic medications. Co-insurance on generic medication is applied by insurance plans throughout the world including the RMBP. Please note that there is a cap to the co-pay amount you pay per drug. The coinsurance will apply to the Out of Pocket Maximum. The co-insurance that you pay for generic and other medication contributes to the overall efficiency of the plan and members stand to benefit from the optimization of the benefit. Please also note that the $ deductible has been eliminated as part of the Pharmacy plan changes. The amount of generic drug copay will vary widely from one person to another, depending on the mix of drugs being utilized. Some members will pay the $25 maximum for a 30 day supply or the $60 maximum for a 90 day supply, but most will pay less because prices for the vast majority of generic drugs are very low. The examples below illustrate the variability in generic copays, depending on drug mix.

2 Generic Drug Drug Cost Days Supply Member Cost A $ Retail $1.50 B $ Retail $2.50 C $ Retail $5.00 D $ Retail $6.00 E $ Retail $25.00 max. F $ Mail Order/CVS $7.50 G $ Mail Order/CVS $10.00 H $ Mail Order/CVS $15.00 I $ Mail Order/CVS $30.00 J $ Mail Order/CVS $60.00 max. 4) What is Step Therapy? This program requires that members who are prescribed certain Brand name drugs first try generics or preferred-brand name drugs. The Step Therapy program was introduced in the Plan on March 1, ) Why are Prior Authorizations for some medications required? Prior Authorizations allow CVS/caremark to ensure the prescription is correct for your condition, gender, and age. In some cases, a member may have prescriptions that would interact with a new medication, which might cause potential side effects or reduce the effectiveness of the new medicine. Your doctor will be asked a few questions and can reply to CVS/caremark directly. Prior Authorization was introduced in the Plan on March 1, 2014.

3 6) I tried the Generic version before we switched to CVS/caremark and it was not as effective as the brand name for my condition. Will my prescription for a Brand name drug be filled? In most cases you should not experience difficulties having your brand name drug refilled. Only your doctor can provide the information relating to you having to take a brand name drug. If needed, your prescribing physician must inform CVS/caremark of the need for you to take a Brand name drug for your condition based on the history of a trial of a Generic alternative. This informs CVS/caremark that you have already undergone step-therapy and were found to require a specific Brand name drug for your condition. 7) My medication does not have a Generic option. Why do I have to pay the Brand Name price? It is important to note that you and the Plan share the cost of all Generic and Brand Name medications. Your share is the coinsurance for these drugs. The introduction of a copay limit per fill for both Generic and Brand Name drugs offers a new level of protection to members in addition to the lowering of the annual Out of Pocket Maximum. 8) What is an Out of Pocket maximum? This is the most a member will pay in copays for prescriptions during the Plan/calendar year. After the limit is reached, the Plan pays 100% for the remainder of the year for covered medications. As an added benefit to the pharmacy benefit, a maximum copay per fill will be introduced to provide support to members with high cost medications. 9) What happens to my existing Mail Order or Specialty medication orders? Express Scripts will transfer the information about your medication to CVS/caremark. Members will receive communications from CVS/caremark about continuing mail order service and the new Maintenance Choice program. CVS/caremark will need new prescriptions from your physician for any prescriptions that are Expired, Compound, or for Controlled Substances. NOTE: Even if your prescription transfers seamlessly, you will need to contact CVS/caremark to arrange new billing and provide credit card information. For your protection, this information will not be shared by Express Scripts.

4 Specialty medications: CVS/caremark will assist you in transferring your Specialty medications to the CVS/caremark Specialty Pharmacy service. It is important to note that these prescriptions should be filled through CVS/caremark s Specialty Pharmacy. Members may choose to have their medication shipped to their home or to their local CVS pharmacy for pick up. Mail order / Maintenance Choice: Members will have the option of receiving their maintenance medication through the mail or to have it dispensed at their local CVS/caremark pharmacy. Note that by making use of this option, the coinsurance for a 90 day supply (3 times 30 days) of your medication is reduced to 2.5 times the equivalent coinsurance of a 3times 30 day supply (as opposed to 3 times). For example: Three 30 day fills could be $10 each for a total of $30, but one 90 day mail order/maintenance choice fill would be $25. 10) Will I be able to use a local pharmacy, not CVS, to fill my 90 day prescriptions for maintenance medications? You can continue to fill 30 day prescriptions at any CVS/caremark network pharmacy. Note that certain non-cvs/caremark branded pharmacies are also part of the network of pharmacies covered through the MIP/RMIP. Members who are on Maintenance medications, are required to transfer to CVS Mail Order or CVS/caremark Maintenance Choice to fill 90-day prescriptions. With Maintenance Choice, you can receive the same benefit as Mail Order and still pick up your prescriptions at a local CVS or have it shipped to your home if you prefer. 11) Are the changes to the Pharmacy Plan going to affect the overseas-based retirees? Overseas-based retirees who refill medications in the USA will be affected by the changes in the Pharmacy plan. Retirees who use local resources outside the USA, and use the services of Vanbreda International or Aetna to process their pharmacy claims, should not be affected. 12) Will overseas-based retirees get a CVS Caremark card that they can use when they are on vacation or trip in the US? Yes, the addresses, including overseas addresses, of retirees have been used to process the delivery of CVS/caremark ID cards. In addition to the physical cards that are scheduled for delivery, members are encouraged to make use of the mobile app and / or print a temporary ID card see instructions in number 16 below.

5 13) When does the change to CVS/caremark become effective? January 01, 2015 is the effective date for the change to CVS/caremark. 14) How can I make contact with CVS/caremark? You can contact CVS/caremark as follows: Phone: customercare@caremark.com Web: 15) Definition of Terms: a. Formulary A formulary is a PBM s (Pharmacy Benefit Manager) list of drugs compiled, in the case of CVS/caremark, by an independent Pharmacy & Therapeutics Committee to review and approve all formulary additions/deletions. The voting members of this Committee are non-cvs/caremark physicians (approximately 14) from across the country from a wide-range of disciplines, pharmacists, and a medical ethicist. The Committee has final authority on all drug coverage decisions. - Formularies usually will offer drugs in each therapeutic class in order for medical conditions to have comprehensive drug coverage. - Formulary management remains a dynamic process as information regarding new drugs, long-term effectiveness and side effects of medications and other criteria are constantly updated. - In order to avoid patient disruption, changes to the formulary are typically made annually (but can be made more frequently if deemed appropriate). - Changes are required to be communicated to members by the plan sponsors or the PBM. - The following main criteria are used to establish the formulary: - Clinical efficacy - Safety - Price A Formulary drug is a drug that is included in the Formulary this can be a generic or brand name drug. Non-formulary drugs are not included on the formulary. b. Chronic Medications A chronic medication is the term used to describe the medication your doctor prescribes once you are diagnosed with a chronic medical condition, such as diabetes or high

6 blood-pressure. Typically these medications will need to be taken for an extended period of time (sometime for life) in order to maintain control of the underlying medical condition. The term can be used interchangeably with the term Maintenance Medication. c. Maintenance Medications See above regarding Chronic Medication. d. Acute Medications An acute medication is the term used to describe the medication your doctor prescribes to treat a medical condition that requires a short duration of treatment conditions such as Acute Lung-infection. e. Specialty Drugs Specialty drugs are used to treat complex medical conditions such as: - Cancer - Multiple Sclerosis - Organ Transplants - Rheumatoid Arthritis Specialty drugs are prescription medications that often require special handling, administration or monitoring. Currently there are approximately 250 Specialty drugs on the market but another 900+ are said to become available in due course. The cost of these drugs can be as much as $ for a year supply of medication. f. Controlled Substance Controlled substances are drugs that have some potential for abuse or dependence. These drugs are federally regulated and require special prescribing principles that need to be adhered to by your doctor; the pharmacy plan and pharmacy benefit manager. g. Compound Medications or Compounds According to the U.S. Food and Drug Administration (FDA),compounding is a practice in which a licensed pharmacist, a licensed physician, or, in the case of an outsourcing facility, a person under the supervision of a licensed pharmacist, combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient. Compounded drugs are not FDA-approved. This means that the FDA does not verify the safety, or effectiveness of compounded drugs. Some component (s) of compound drugs might have FDA approval however, it is important to note that the FDA approval needs to include the dosage form that the compound is being presented in, for the compound to be considered for coverage.

7 h. Per Fill Fill or refill refers to the process whereby you get the drugs that has been prescribed by your physician dispensed by a pharmacist. Typically, when you have a well-controlled chronic medical condition, your doctor will provide a prescription for the medication that will allow a number of refills allowing the pharmacist to dispense the medication without you having to visit the doctor again. There is a limit to the number of refills or repeat fills - that can be allowed on a prescription. The coinsurance and maximum copay will apply to each drug each time it is dispensed by the pharmacist. 16) How do I access the mobile app or print a temporary ID card? Please find attached instructions on the CVS Mobile App and Temporary ID Cards. All members will be issued new ID cards from CVS/caremark. While all efforts are being made to have cards delivered to members homes by January 1, we would like to make you aware of three alternatives for identification at the pharmacy should your card not arrive by January 1. You may: Use the CVS/caremark Mobile App*. Click here to find details. (OR) Print a Temporary Member ID Card*. Click here to find details. (OR) Have the Pharmacist contact CVS/caremark on your behalf to verify coverage. CVS/caremark has provided instructions to all their network pharmacies on how to verify eligibility for World Bank Group members. They may require a photo ID. Should you have any questions, please contact CVS/caremark at * Please note that you need to select the CVS caremark App or The CVS pharmacy option has different functionality. Also note that registration for the App and Temporary Member ID cards become active on January 1, If you attempt to register prior to January 1, 2015 your account information will not be available. Instructions for registration are available here. Thank you. Human Resources Compensation and Benefits