New Prescription Drug Program for UniCare State Indemnity Plan/Medicare Extension (OME) Members

Successfully Implemented; A Few Bumps; Huge Savings for Members and the Commonwealth

Prescription Drugs

A Successful Implementation

Last summer the GIC embarked on a complex project to implement a new prescription drug program for UniCare State Indemnity Plan/Medicare Extension (OME) members.  Called EGWP for Employer Group Waiver Plan, the GIC-provided plan is a group Medicare Part D plan. We provide an additional “wrap” program to close the gaps between a standard Medicare Part D plan and the members’ previous non-Medicare plan coverage.

All agency departments were deployed to make the program a success.  Weekly teleconference meetings with SilverScript, our consultant, Buck, and CVS Caremark kept the project on target with timely decisions reached on systems, operations, communications, budgeting, invoicing, and the formulary. 

One of the most challenging aspects of the program was the required data match with Centers for Medicare and Medicaid (CMS) records.  With over 70,000 members enrolled in the program, there were a lot of data discrepancies that needed to be worked through: spelling of first or last name, use of Junior or another suffix, date of birth, or totally different first names.  File exchanges began in late spring and through file culling and outreach, the GIC achieved the cleanest files out of SilverScript’s entire book of business and the lowest number of errors for any of CVS Caremark’s January 1, 2016 EGWP implementations.

The implementation of a Medicare Part D plan also meant the GIC needed to accelerate the timeline to enroll retirees and their covered spouses in Medicare coverage.  Medicare requires that certain documentation be received before enrolling in Medicare.  The GIC revamped its retirement and turning age 65 procedures, forms, and mailings to conform with these requirements while making the materials easy to understand.  The Medicare plan enrollment process was automated and a tracking system was developed for ease of data retrieval.  New eligibility screens helped the GIC customer service units answer member questions about the status of their mailings.

An additional CMS requirement is that all members be offered the opportunity to opt out of the SilverScript prescription drug coverage.  However, if members did opt out, they would lose their GIC health, prescription drug and mental health benefits.  The GIC conducted a comprehensive outreach campaign to let retirees know they should not opt out of coverage.  A special edition of the September newsletter devoted to the EGWP was mailed to all retirees.  We also collaborated with the Retiree Association to get this important message out.  A home mailing with 46 questions and answers was mailed in advance of the required opt out mailing.  As a result, no member opted out of coverage unless they had an extenuating circumstance and GIC staff called these members to be sure that was the case.

To ensure that members who live outside of the country (where Medicare Part D coverage isn’t available) still had health insurance, the GIC assisted these members with enrolling in the non-Medicare UniCare State Indemnity Plan/Basic. 

Federal rules prohibited the launch of the SilverScript website before October 1, 2015, so the GIC developed a work around plan in cooperation with CVS Caremark and SilverScript.  We also got out the word that very low income retirees might be eligible for subsidies so they could take advantage of these resources. 

Learn more about UniCare OME Prescription Drug here.

Member Concerns

Even though the move to SilverScript has been a resounding success for members and the GIC, there have been some bumps in the road.

The GIC has heard concerns from OME members about higher costs, primarily for some generic drugs. Copayments have not changed for members enrolled in the OME plan. OME members pay the same copayments that went into effect on July 1, 2015.  As always, if the actual cost of a drug is less than your copayment, you pay the lower cost. For instance, a member may pay only the actual cost of $20.93 for a generic drug because it is lower than the member’s $25 generic copayment for a 90-day supply at a preferred network retail pharmacy.  However, for some members, the actual cost of their generic drug may be higher through SilverScript than it was through CVS Caremark. This difference in cost is due to SilverScript having a different drug list and pricing than CVS Caremark. Despite this difference in price, the member will pay no more than the copayment for that drug and in many cases the actual cost is still less than the copayment.

Some members were able to get only a 30-day supply of a drug when they got the first calendar 2016 refill of their medication. These members were also told that they would be able to get the full 90-day supply of their drug the next time they refilled that prescription. In most cases, members were refilling drugs that either are not covered by Medicare or are not on the SilverScript formulary, the drug list for the Medicare Part D portion of their coverage. But, the drugs are covered through the members’ additional coverage provided by the GIC. In other cases, members needed to get a prior authorization before they could get the full 90-day supply.

Due to Medicare rules, during the first 90 days of the plan year, SilverScript provides a temporary 30-day supply of a drug that is not on its formulary or if the drug requires a prior authorization. After the first time that non-formulary drug is filled, each subsequent refill is processed and covered through the additional coverage provided by the GIC. For more information about a 30-day temporary supply, see Chapter 3, Section 5.2 of your SilverScript Evidence of Coverage.

Other members have not been able to refill their prescription because the drug was prescribed for a condition that is not a “medically accepted indication” for the use of that drug.  Medicare requires that prescription drugs may only be used for a diagnosis or condition approved by the U.S. Food and Drug Administration (FDA) or one supported by certain reference books (see Chapter 3, Section 3 of your SilverScript Evidence of Coverage). One such medication is the Lidoderm patch. It is available on the SilverScript formulary but only for the FDA-approved treatment of neuropathic pain related to shingles.  In this case, members who cannot refill the Lidoderm patch for treatment of other conditions will need to talk to their doctors about alternative medications.

Program Brings Huge Premium Savings and Additional Benefits

Despite well-publicized skyrocketing prescription drug costs, the new EGWP program is reaping huge savings for both members and the Commonwealth.  First year estimated savings will come in around $30 million total.  Lower drug costs were the largest factor leading to lower premiums; the UniCare State Indemnity Plan/Medicare Extension premium went down 7.2% effective July 1, 2016.  For retired teachers in the GIC RMT (non-municipal) program, the premium went down 10.3%.

In addition to premium savings, very low income members can now access prescription drug premium subsidies.  Some members prescribed certain drugs are paying lower costs than they did under the CVS Caremark program, as the SilverScript prescription drug formulary is more favorable (the reverse of the scenario outlined above).  Members can also now get their 90-day supply of prescription drugs at any participating retail pharmacy (retirees continue to have the lower mail-order copay at certain pharmacies, such as CVS Pharmacy and Navarro).  They can also now get their prescription drugs at nursing home and long term care facilities.

The bottom line – the new SilverScript program is an overwhelming success for both members and the Commonwealth.


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