With the August 1st change in Pharmacy Benefit Managers (PBM) from CVS Caremark to MedImpact (MI), it is important to note that PBMs have different formularies and manage their medication costs differently. Using a medication not in the formulary may result in a higher cost. As always, don’t forget that any amount you pay toward a covered prescription applies to your annual deductible and/or out-of-pocket amounts in your plan.
Medications Not Covered
In relation to the change in PBMs, CWRU adopted the drug formulary (list of prescription drugs covered by a prescription drug plan) maintained by MI. This may cause some prescriptions to cost more, or some to cost less, than they did with CVS, as certain medications may move between tiers or become non-formulary. During the 90-day grandfathering period (through October 31, 2018), if your prescription is now a non-formulary drug, you and your physician will receive a notification letter from MI; it is advisable to speak with your healthcare provider to discuss a therapeutic alternative or generic drug in the MI formulary. If that is not possible due to a medical necessity, your doctor can request a prior authorization (PA) review with MI for you to remain on the non-formulary medication. Keep in mind that a medication not in the formulary may be more expensive than the formulary option. Please refer to the MI preferred drug list for preferred generic and brand drug options.
Preventive Medication Costs
Every PBM also manages their own preventive (tier 0) drug list, and MI has developed their preventative drug list (list of medications that are considered essential health benefits by the Patient Protection and Affordable Care Act) based on federal guidance. These drugs are covered at zero cost to the member, with no co-pay or deductible.
Employees enrolled in the High Deductible Health Plan (HDHP) can bypass their deductible and pay only the co-payments for certain medications to encourage compliance with the nature of these medications. Once the out-of-pocket maximum is met, prescription costs are covered by the HDHP at 100 percent.
Medication Cost Management
If you have a Flexible Savings Account (FSA), keep in mind that CWRU makes its contribution to these accounts in January to help with out-of-pocket prescription costs. These funds as well as funds from a Health Savings Account (HSA) can be used to pay for prescriptions and medical care.