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University of KentuckyRetiree Prescription BenefitPrescription Benefit ManagementLucy B. Wells, RPh.Prescription Drug Benefit ManagerOctober 2013
UK Retiree PrescriptionBenefit Pre-65 (non-Medicare Retirees)- Early Retirees- Working Retirees Medicare Retirees- Medicare A and B Participants- No longer working
Pre-65 & Non-MedicareRx Benefit Universal Prescription Benefit Plan for all healthplans (UKHMO, PPO, EPO, etc) Same Rx Benefit as for Active Employees(use same Rx ID card as when active employee) Spouses/Dependents – covered under same IDnumber as retiree Administered by ExpressScripts – UK direct accessto enrollment
Medicare Retiree RxBenefit UK Medicare PART D Prescription Drug Plan New ID card and ID numbers Medicare Covered Spouses have own ID card andunique ID numbers Administered by Express ScriptsCMS (Medicare) controlsenrollment
Pre-65 & Non-Medicare RxBenefitActives and Retirees 65 yearsRetail (up to one month supply)GenericFormularyNon-formularycoinsurance minimum20% 840% 2050% 40maximum 50 60No MaximumExpress Scripts Home Delivery or UK RetailPharmacies (35-90 day supply)GenericFormularyNon-formularycoinsurance minimum10% 2430% 6040% 120maximum 100 120No Maximum5
Medicare Rx PrescriptionBenefit (2013)Medicare RetireesRetail (up to 90 day imum20%No Minimum40% 2050% 40maximum 50 60 100Express Scripts Home Delivery (35-90 day m10%No Minimum30% 6040% 120maximum 100 120 2006
Medicare Rx PrescriptionBenefit (2014)Medicare RetireesRetail (up to 90 day imum20%No Minimum40% 2050% 40maximum 50 60No MaximumExpress Scripts Home Delivery (35-90 day m10%No Minimum30% 6040% 120maximum 100 120No Maximum7
UK Retiree PrescriptionBenefitFormulariesPre-65 Retirees Medicare Retirees Medicare Retirees2014- Express-Express Scripts 2013- ExpressScripts Medicare Scripts MedicareHighNational Prime High PerformancePerformanceFormularyFormularyFormulary
Drug List (Formulary)National Preferred- Highest presence of Brand name drugs- Least level of cost management2005-2006Prime Encourages more generic usage More non-formulary brand drugs Retired by Express Scripts 2013High Performance High focus on generics Branded products preferred where notherapeutic generic alternative2013-2014
UK Retiree Rx FormularyWhy High PerformanceFormulary?
Patent ExpirationLandscapeIn Billions of DollarsBlock-Buster BrandsExpiring!! 402001 -2011: 35 126Billion20022004 30 25 20 15 10 5 0200120032005200620072008 20092010201120122013201411
Key Brand Drugs Losing PatentProtectionMore than 64.3 billion within the next five years20132014 14.2 BillionAcipHexCymbaltaDiovanInvegaLidoderm 5%NiaspanOpana ER*OxyContin*Reclast/ZometaSuboxone SLTemodar 18.2 BillionActonelAveloxCelebrexDetrol LAEvistaExforgeLoestrin 24 FELumigan 0.03%LunestaNexiumTrilipixXeloda2015Annual Sales 15.5 BillionAbilifyAloxiAndrogelAvodartFocalin XRGleevecLovazaNamendaOrtho Tri-Cyclen LoPatanolTreandaWelcholZyvox tablets20162017 11.2 quel XRTygacilZetia 5.2 tteraTamifluTreximetVytorin* not AB ratedConfidential and Proprietary Information 2013 Express Scripts Holding Company. All Rights Reserved.12
Market ProjectionRare and Specialty growth2014201182%18%Specialty Rx spend: 11 billionTraditional Pharmacy Spend74%26%Specialty Rx spend: 19 billionSpecialty Pharmacy SpendSources: Express Scripts Drug Trend Report; MarketScan Commercial Database
UK Specialty Utilization1.9% ofmembersuseSpecialtyPre-65 PlanMedicare Retirees5.6% of27%73%Traditional Pharmacy Spend25%membersuseSpecialty75%Specialty Pharmacy SpendSources: Express Scripts Drug Trend Report; MarketScan Commercial Database
Plan DifferencesWhere are Pre-65 RetireeRx Benefit andMedicare Rx BenefitDifferent
Plan DifferencesPre-65 RetireesMedicare Retirees90 day limited to ESI Mail Order &UK Retail Pharmacies90 day allowed at any Medicare Part DParticipating Pharmacy – discountonly at Mail OrderSpecialty Medications – after 1st fill,subsequent fills at UK RetailPharmacy or AccredoSpecialty Medications – all fillsallowed at any Medicare Part Dparticipating Specialty providerPHARMA Copay Cards AllowedPHARMA Copay Cards ExcludedHealth Care Reform – 0 Copays onHealth Care Reform – Does notapply to Medicare Part D Planspreventive services - Vitamin D , Aspirin,Colonoscopy Prep, Chantix 8 Minimum on Generics per 30daysNo Minimum Copays on Generics
Coverage DifferencesDiabetes Testing Supplies Pre-65 – Covered on Express Scripts Card Medicare Rx – Covered on Red, White, Blue Medicare CardMedicare B Covered Drugs – Neb Solutions,Transplant Medications, some Oral Chemotherapy Pre-65 – Covered on Express Scripts Card Medicare Rx – Covered on Red, White, Blue Medicare CardPart D Excluded Drugs – Vitamins/minerals, Coughand Cold Pre-65 - Covered on Express Scripts Card (if Rx , not OTC) Medicare Rx – NON-CoveredShingles Vaccine Pre-65 – Covered as Medical or Rx Benefit after age 60 Medicare Rx – Covered ONLY on Prescription Benefit
UK Medicare Rx BenefitExpress Scripts Medicare (PDP)for the University of Kentucky This IS a Medicare Part D Plan– Do not enroll in a different Part D or MedicareAdvantage Plan– Subject to all CMS Medicare D Requirements
Standard Medicare Part D Benefit, Jan 2014Enrollee Out-ofPocket SpendingCatastrophicCoverageMedicare Part DBenefitMedicare pays 80%5%Plan Pays 15%Member Copays the Greater of 5% or 2.55 forGeneric drugs, and the Greater of 5% or 6.35 forall other drugs)Coverage Gap –BRAND -50% PharmaDiscount, 2.5% Plan PayGenerics - Plan 22%Coverage50% PharmaDiscount7% Plan Pay747.5% CoInsurance2.5% Plan PayPartial Coverage25%Deductible78% Co-Ins22% Plan PayMedicare pays 75%Total Drug Costs will vary withB/G mix( 4550 out of pocket)Out Of Pocket MemberCopay Pharma 50% 2,850 in Total Drug CostsTotal Drug Cost Membercopay Plan Cost 310 deductible( 310 out of pocket)Confidential and Proprietary Information 2013 Express Scripts Holding Company. All Rights Reserved.19
UK Medicare Part D (EGWP) NO Deductible Complete Coverage thru the Medicare Gap(aka “Donut Hole”) Medicare defines Coverage Gap when TotalDrug Spend (TDS) 2970 (2013), reducedto 2850 (2014) Catastrophic Coverage begins at 4750TrOOP for 2013, 4550 for 2014
Enrolling in UK Medicare Rx Sign up for Medicare Parts A and B within3 months of 65th birthday Complete Medicare Carveout and Medicareenrollment form with UK HR BenefitsRx UK sends file to Express Scripts, who sends on to CMS forprocessing When CMS approved Express Scripts will send letter andWelcome Packet with new ID card
UK Medicare Part D (EGWP)EOB Medicare requireddocument Sent monthlyfollowing any RxactivityXxxxxxxx
Medicare Part D – LEP LEP LATE ENROLLMENT PENALTY1% per Month of Standard Medicare DPremium– Receive a letter from Express Scripts– Documentation of Creditable Coverage– UK Benefits Pharmacist can provide ExpressScripts with documentation for you IF you werepreviously covered on UK Prescription plan
Medicare Part D – IRMAA IRMAA Income Related Monthly AdjustmentAmounts– Paid Directly to Social Security Administration
Medicare Part D – LIS LIS Low Income Subsidy– Monthly Premium Reimbursement– Reduced Copays on PrescriptionsIn 2013, you may qualify if you have up to 17,235 inyearly income ( 23,265 for a married couple) and up to 13,300 in resources ( 26,580 for a married couple).https://secure.ssa.gov/i1020/start
Managing Drug Spend
KYRx CoalitionPharm-Assist Offering Free counselingservice via livepharmacists(855)-218-5979Dedicated Clinical Pharmacists Identification of lower costprescription alternatives Contacting physician tofacilitate seeking authorizationfor lower cost alternativetherapies Educational resources formembers – adverse effects,drug interactions and generalmedication informationLucy WellsLea GogginCarrie IsaacsMatt McMahanAllison RussellKimberly Bottom
KYRx Pharmacy Services New Member ServicesCopay CounselingID CardsSavings OpportunitiesMedicare Retiree transitionTherapeutic/Clinical InformationPhysician Liason
KYRx CoalitionCurrent Membership
Generic Discount Program 4.00 for 30 day supply 10.00 for 90-day supply OVER 400 generic drugs offered at rates lowerthan Rx benefit Obtain 90-day Rxs without using Express ScriptsCard to use the discount program (Kroger and WalMart for pre-65 Retirees) Let the pharmacist know what other medicationsyou are taking
90-day Maintenance RxsWill it save memoney? Do I get 3 months for 2 copays? Depends on the cost of the Rx. Minimum Copays triple, maximums onlydoubleWhere can I get90-day supplies? Kentucky Clinic Pharmacy – now open to all Express Scripts Home Delivery (Mail OrderPharmacy) For Medicare Rx (any 90 day participatingpharmacy)How do I enroll inthe ExpressScripts Mail OrderProgram? http://www.express-scripts.com 1-877-242-1864 Call KYRx Pharmacists for assistance – We cancontact your MD 859- 218-5979 ion delivery.pdf
Coupons and SamplesCan SAMPLES COST me MORE inCOPAYS?Coupons/Samples provide low or no-costfirst fillRefills may be more expensive than otherlower cost brand or generic alternativesProducts with coupons may be “new” drugs(slightly modified “old” drugs with little orno therapeutic advantage) – Dex, Lev, XR
Direct to Consumer/PhysicianMarketingNasonexCopay –Nasonex 74Fluticasone (genericFlonase) 8Flunisolide (genericNasalide) 8Triamcinolone (genericRhinocort AQ) 15
Direct to Consumer/PhysicianMarketingNexiumCopay –Nexium 114 Pre-65 Plan 60 Medicare Rx PlanLansoprazole (generic Prevacid)Omeprazole (generic Prilosec)Pantoprazole (generic Protonix) 8.00
Medication Copays – Pre 65 Plan90-Day Supply at RetailPharmacy (3 x 30 days)90-Day Supply at ExpressScripts Home DeliveryPharmacy or UK PharmacyCrestor 5 mg Tablets 263 188Avodart 0.5mg 197 140Lumigan Eyedrops 170 120Benicar 20mg Tablets 153 120Actonel 150mg Tablet 240 171 4,092 2,956DrugTotal Annual Copays
Therapeutic Alternatives - Pre-65 Plan90-Day Supply at RetailPharmacy (3 x 30 days)90-Day Supply at ExpressScripts Home Delivery orUK Pharmacy 263 188 24 24 197 140Finasteride 5mg 24 24Lumigan Eye Drops 170 120 24 24Benicar 20mg Tablets 153 120Losartan 100mg 24 24Actonel 150mg Tablet 240 171Ibandronate 150mg 39 24Previous Annual Copay 4,092 2,956New Annual Copay 540 480DrugCrestor 5 mg TabletsAtorvastatin 20mgAvodart 0.5mgLatanoprost Eye DropsConfidential and Proprietary Information 2013 Express Scripts Holding Company. All Rights Reserved.36
Medication Copays – Medicare Rx90-Day Supply at RetailPharmacy (2013/2014)90-Day Supply at ExpressScripts Home DeliveryPharmacy (2013/2014)Crestor 5 mg Tablets 180/ 237 120/187Avodart 0.5mg 178/ 178 140/ 140Lumigan Eyedrops 116/ 145 86/ 114Benicar 20mg Tablets 110/ 138 82/ 109Actonel 150mg Tablet 173/ 217 120/ 171 3,028/ 3,580 2,192/ 2,884DrugTotal Annual Copays
Therapeutic Alternatives - Medicare Rx Plan90-Day Supply at RetailPharmacy (2013/2014)90-Day Supply at ExpressScripts Home DeliveryPharmacy (2013/2014) 180/ 237 120/187 24 13 178/ 178 140/ 140 16 11 116/ 145 86/ 114 16 9Benicar 20mg Tablets 110/ 138 82/ 109Losartan 100mg 16 9Actonel 150mg Tablet 173/ 217 120/ 171Ibandronate 150mg 23 22Previous Annual Copay 3,028/ 3,580 2,192/ 2,884New Annual Copay 380 256DrugCrestor 5 mg TabletsAtorvastatin 20mgAvodart 0.5mgFinasteride 5mgLumigan Eye DropsLatanoprost Eye DropsConfidential and Proprietary Information 2013 Express Scripts Holding Company. All Rights Reserved.38
Questions?
Coverage Differences Diabetes Testing Supplies Pre-65 - Covered on Express Scripts Card Medicare Rx - Covered on Red, White, Blue Medicare Card Medicare B Covered Drugs - Neb Solutions, Transplant Medications, some Oral Chemotherapy Pre-65 - Covered on Express Scripts Card Medicare Rx - Covered on Red, White, Blue Medicare Card .
