FAQs for 2019 Health and Pharmacy Plans

Q. What will the new co-pays be beginning January 1, 2019?

Q. What type of doctors are considered primary and what type are considered Specialists under the new copays? 

Primary care providers typically offer general health services and are the initial contact in most cases for ailments. Examples of primary care providers are family and general practitioners, internal medicine providers, naturopaths, geriatric providers, and pediatric providers. Specialists provide care that is focused and generally restricted to a very specific field of medicine. Some common examples of specialist providers include cardiologists, endocrinologists, gastroenterologists, and neurologists.
  • The following rehabilitative services will be subject to the same copay as primary care providers:
    • Physical Therapist
    • Occupational Therapist
    • Speech Therapist
    • Chiropractor
    • Acupuncturist

Q. How will my pharmacy plan change?

Effective January 1, 2019, the prescription drug formulary will change to the Express-Scripts (ESI) National Preferred Formulary.  In addition, ESI will be implementing cost containment initiatives such as expanded prior authorization and drug quantity management. Please rest assured, you will be able to get the medications you need. Updating our plan to the National Preferred Formulary will have a positive impact on the future cost of the plan for the State, active employees, and the retirees covered under the State’s plan.  Comprehensive communications will be provided to employees and retirees on the state plan, with sufficient lead time, once we get closer to the transition.

Q. How is ESI’s National Preferred Formulary developed?

ESI determines which medicines to include on its drug list (the standard national formulary).  ESI has a National Pharmacy and Therapeutics Committee (“P&T”) that is made up of independent physicians and other medical experts who are not employed by ESI.  The P&T Committee is selected based on their contributions to medical and pharmacy practice and clinical expertise in their area of specialty. In order for a drug to be recommended to be included on the formulary, the P&T Committee reviews medical literature, standards of practice, scientific studies, personal experience, and generally accepted clinical practice guidelines to confirm that a medication is safe and effective. This process ensures the medicines included on its National Preferred Formulary (NPF) are the best combination of clinical appropriateness and cost effectiveness.
The NPF is generated on a periodic basis (typically twice per year for ESI) to keep pace with the ever-changing pharmaceutical industry, both to contain costs and to enhance quality measures.

Q. Where can I find ESI’s National Preferred Formulary and exclusion list?

Although this list is fluid and may change again before it is implemented on January 1, 2019, this link provides a list of excluded drugs and their preferred alternatives to ESI’s current NPF.  

Q. What if my medication is on a list of “excluded medications”? 

In short, there will be a grace period at the beginning of 2019 in which your prescribing provider may request a clinical exception review. If your clinical exception is denied, you have the right to appeal the decision.

Q. Will there be a grace period to transition to a new medication if I need to change prescriptions or request an exception to the ESI National Preferred Formulary?

There will be a grace period from January 1st through March 31st, 2019. This will allow sufficient time to adjust your prescriptions or request an exception. Express Scripts will be contacting you and your physician/provider directly in advance to discuss alternatives so that a coordinated effort can be made to either adjust your prescription or begin the exception/appeal process before the end of the 90 day grace period.   

Q. What if there are no appropriate alternative medications on the preferred list? Is there an exception?

IIf your physician/provider determines that the alternatives are not appropriate for your therapy, your physician/provider can request a clinical exception review on your behalf. If the exception is granted you will pay at the non-preferred brand name tier copay, which is 40%.

Q. What if an exception request is denied?

Although an exception is approved more often than not, the employee can begin an appeal process if the exception request is denied. The appeal process would proceed as follows:
  1.  Medical necessity exception sent to ESI by member physician/provider. Decision rendered within 24-72 hours. If approved, no further action is needed.
  2.  If the exception is denied, the member can use the State’s current contracted third party independent pharmaceutical appeal service. Their turnaround time for decision is 2 to 5 days. If the exception denial is overturned, ESI will reverse the denial and no further action is required.
  3.  If the denial is upheld, an appeal can be made to the highest level, which would be Department of Financial Regulation at the State, per statute.

Q. Will using an excluded drug cost more?

If a member receives an exception, the member would pay at the non-preferred brand name tier copay, which is 40%.  The member can submit a separate appeal to request that the medication be paid at the preferred brand name tier, which, if approved, would result in a co-pay of 20%.

Q. Who else participates with ESI's National Preferred Formulary?

Express Scripts provides pharmacy benefits to 83 million members.   60% of ESI’s non-governmental and nearly all of their State clients use the National Preferred Formulary.  The neighboring States plans of New England also currently use the National Preferred Formulary.

Q. Are there quantity limits on medications?

The State’s plan currently has drug quantity management in place today. The changes for 2019 is to expand the program to include narcotics, opioids, and other such drugs subject to abuse.  This management is an attempt to mitigate a variety of practices used to abuse medications through an enhanced oversight coordination between Express Scripts, the pharmacies, and the physicians.

Q. I am a State retiree on the State Health Care Plan.  How does the transition to National Preferred Formulary impact me?

This depends on whether you are on Medicare or not.  If you and/or your dependent(s) are on Medicare, the drug plan you have is called a Medicare EGWP plan, and the change to the active employee formulary does not impact you.  The current formulary that is associated with the Medicare EGWP plan, called the Premier Access Formulary, is very similar, but slightly different from the current open formulary on the active employee plan because of federal rules, and will NOT be affected by the changes to the active employee plan formulary. However, the Medicare EGWP Premier Access Formulary will be subject to the usual updates that occur every year.
If you are not on Medicare, then the above plan for active employees applies to you.  These changes impact you in the same manner as active employees.