Q&A for Group Administrators: Wellmark Announces Strategic Pharmacy Program Changes to Help Control Drug Spend

Transcription

1 Learn More Q&A for Group Administrators: Wellmark Announces Strategic Pharmacy Program Changes to Help Control Drug Spend Iowa and South Dakota Pharmacy Benefit Plans This document answers questions regardingupcoming pharmacy tier changes, and updates for hightrend/high-spend drugsand compounds designed tocontrol drug spend. Wellmark will introduce strategic pharmacy program changes designed to control drug spend beginning July Q: Why is Wellmark changing some pharmacy programs? A: Drug spend is rising at a rapid and unsustainable rate. Addressing these cost trends is crucial to assuring a sustainable health care system and managing costs. Q: Whatprograms will change? A: Fiveareas will be impacted: 1. July formulary changes 2. Specialty drug 3. Insulin utilization management 4. ADHD utilization management 5. Compound management July formulary changes Q: Why is Wellmark making formulary changes? A: To help control costs for members, we regularly update the Wellmark Drug List of covered drugs with a committee of statewide pharmacists and physicians. Sometimes, the cost share for certain drugs may change. This means there will be changes that may affect pharmacy costs and coverage. Q: Whenwill theformulary changes become effective? A:July 31, Q: What drugs are impacted by the formulary changes? A:Below is an overview of the July formulary changes: 6/15 Page 1 of 7

2 Drugs moving to a lower tier Drug name Future tier Advair Diskus 2 Advair HFA 2 AsmanexHFA 1 Astagraf XL 2 Eliquis 2 Janumet 2 Janumet XR 2 Jentadueto 2 Levemir 2 LevemirFlexpen 2 LevemirFlextouch 2 Pradaxa 2 Tradjenta 2 Victoza 2 Drugs moving to the highest tier or removed from formulary Actoplus MET XR Cambia Humulin Android Elidel Menest Apidra Femring Nasonex Avandia Gralise Proventil HFA Bethkis Horizant Ventolin HFA Binosto Humalog/Humalog Mix Vimovo Brisdelle Drugs no longer covered First-Omeprazole Fluoride Products 6/15 Page 2 of 7

3 Drugs moving from tier 1 to tier 2 Estrace Drugs moving from tier 2 to tier 3 Byetta Elmiron Epzicom Multaq Ranex Drugs moving from tier 3 to specialty preferred Kuvan Q:How do I find a list of drugs on the different tiers? A: The Wellmark Drug List is updated regularly on Wellmark.com. The Drug List is on the right side of the home page under Quick Links. The Wellmark Drug Listshows what tier a drug is on, information about the drug and possible drug options. Q: Whatoptions do my employees have if they are impacted by these changes? A: Wellmark and your account representative are here to help. Below are options they may consider: 1. Look for different options for the medication. Members may visit Wellmark.com and look for thedrug on the Wellmark Drug List to see the drug s tier and a list of possible lower-cost options. 2. Contact the physician who prescribed the drug to get a new prescription to move to a generic or another alternative medication. If a generic alternative is available, and these drugs are approved by the FDA to treat the illness or condition, the member will pay a lower out-of-pocket amount. 3. Members may keep taking the drug, but if they do, they will pay the higher cost share. To see the full cost of the drug, members may log in to mywellmark.com and click on the Prescriptions Drugs tab, and then click Wellmark Drug List (Price & Save Tool) in the Prescription Drug Tools box.members may also call your pharmacist for the drug cost. Specialty drug program changes Q: What are thespecialty drug program changes, and when will they be effective? A:Specialty drugs are the fastest growing and most expensive segment in pharmacy today and 6/15 Page 3 of 7

4 encompassed 28 percent of Wellmark s total drug cost in Wellmark expanded our specialty drug program to the following conditions to manage the increasing cost. Condition Drug Changes Effective Date Hepatitis C Chronic inflammatory disease Multiple sclerosis Wellmark will implement a preferred drug strategy with Harvoni and Solvaldi for treatment of hepatitis C. Viekira Pak and Olysio will be added as non-preferred therapies and will require the use of the preferred drugs. Non-preferred therapies will move to the nonpreferred specialty tier on the formulary. To help control member costs, Wellmark will add Entyvio as a non-preferred therapy to the tumor necrosis factor (TNF)-α inhibitor preferred drug plan design. We will alsorequire trials of both preferred TNF-α inhibitors, Enbrel and Humira, for all non-preferred therapies in patients with a diagnosis for which both products are indicated. This includes Humira as the preferred drug for pediatric Crohn s Disease. To create cost savings for our members, Wellmark will update the multiple sclerosis (MS) utilization management program to require prior authorization for all MS drugs, including orals. Wellmark will update the preferred drug plan design to include Avonex, Aubagio, Rebif, Tysabri and Lemtrada as nonpreferred therapies. Trials of two out of the five preferred therapies, Copaxone 20mg, Extavia, Gilenya, Plegridy and Tecfidera, will now be required. July 1, 2015 for new users (changes will not affect current users) July 1, 2015 for new users (changes will not affect current users) August 1, 2015 for new users (changes will not affect current users) Q: What can I, as an employer, do to address the rapidly expanding specialty drug market? A:Wellmark offers a comprehensive specialty drug management program that you should consider implementing for the upcoming plan year. The program has three components: 1. Ensure specialty drugs are covered under your pharmacy benefit. 6/15 Page 4 of 7

5 2. Limit specialty drug distribution. 3. Implement a preferred specialty drug strategy. Please speak to your Wellmark representative to learn more. Insulin utilization management changes Q: What insulin program areas will be impacted, and when will they be effective? A: With no generic or biosimilar availability for insulin and to keep our members costs controlled Wellmark is implementing the following management strategy: Management Strategy Insulin tier change Require prior authorization Convert to preferred testing product Changes Non-preferred insulinsapidra, Humulin, Humalog, Humalog Mix and Afrezza will move to tier 4. Members on non-preferred insulin products should contact their physician aboutusing a preferred insulin product. Medical necessity utilization management criteria will be implemented to encourage the use of preferred products: Novolin, Novolog or Novolog Mix. If the member uses a non-preferred drug, he/she will need to obtain prior authorization approval. Members will need to convert to One Touch, the preferred blood glucose product.members on non-preferred products will receive instructions and ongoing communications on how to acquire a new glucose meter at no additional cost. Those using insulin pumps will not be required to change strips if they are not compatible. Effective Date July 31, 2015 January 1, 2016 January 1, 2016 ADHD utilization management programchanges Q: How is Wellmark enhancing its current ADHD utilization management program, and when will it be effective? A: Wellmark will enhance its current ADHD utilization management program with the following: Management Changes Effective Date 6/15 Page 5 of 7

6 Strategy Add quantity limits Require prior authorization For members safety, Wellmark will add quantity limits on all stimulant drugs regardless of age to ensure maximum daily dosing recommendations are followed. Wellmark will now apply prior authorization criteria to adults, age 18 years and older, for both brand and generic long-acting stimulants. The change will encourage clinically appropriate utilization of these medications and direct members to try generic immediaterelease stimulants first before moving on to the more costly alternatives. August 15, 2015 August 15, 2015 Compound management program changes Q: How is Wellmark enhancing its compound management program, and when will it be effective? A: In response to rising costs for compound drugs and for the safety of our members, Wellmark developed a compound management strategy. Management Strategy Evaluatecompound ingredients to identify needless cost and waste Require prior authorization for compound medications that exceed $500 Changes With members safety in mind, Wellmark will not cover compounds containing vitamins, minerals, over-the-counter and non-fdaapproved ingredients, compounds for cosmetic use, or compounds for performance enhancement. The criteria applies when compounds are used in accordance with FDA-approved indications, supported uses,and when they are administered using current, accepted practice guidelines. This will contain costs and, most importantly, keep your employees safe. Effective Date July 31, 2015 January 1, 2016 Q: Why are these changes necessary? A: By continuously monitoring for clinically unproven ingredients used in compound medications, the program will eliminate unnecessary spend for these medications while ensuring member safety. Q: What if a compound drug is medically necessary? 6/15 Page 6 of 7

7 A: Wellmark recommends youcontinue to cover the types of compounds that members need when covered by their pharmacy benefits. However, generally, compound medications do not provide additional clinical value over what is commercially available and FDA approved. For more information Q: Areadditionaleducational materials available about these changes? A: These drug updates may be challenging to understand, but Wellmark and your account manager are here to help. Wellmark created fact sheets that provide high-level information on these updates. Please speak to your account manager to obtain these communications. More communications on these updates will be available through the summer and fall. As always, your account manager will answer additional questions. Q: Where shouldmy employees go for more information about these drug changes? A: If your employees have questions about the changes to thesedrug policies, they are encouraged to call Wellmark Customer Servicevia the number on the back of their ID card. 6/15 Page 7 of 7