Prescription Drug Coverage - Express Scripts
Diabetes Care Value Program through Livongo:
For those enrolled in the Maritz medical plan who have been diagnosed with Diabetes, we want to help you monitor your condition and remain adherent with your medication. For 2019, you are eligible to opt-in to this program at no cost to you. Once enrolled, you receive the following:
Free Livongo cloud connected smart glucose meter
Remote monitoring with real-time (within 3 minutes) outreach driven by dangerous readings via phone, text and email
Coaching by Livongo Certified Diabetes Educators and Express Scripts Diabetes Specialty Pharmacists
Free unlimited Livongo InTouch® strips and lancets
Mango Health app to help you stay engaged and earn rewards
Express Scripts will notify Livongo of all covered members who have had at least one claim through the Maritz prescription drug program for diabetic supplies or medication. Livongo will send outreach communications to you inviting you to enroll in the program.
You can also contact Livongo directly to register and opt in to the program at welcome.livongo.com/Maritz or call the Member Support Call Center at (800) 945-4355 for additional information. When prompted for the Client Specific Registration Code, enter Maritz.
Specialty Drug Management Programs:
Starting January 1, 2019, certain drugs ordered through Accredo (the Express Scripts pharmacy for specialty drugs) for a 30-day supply will be limited on the initial fill to a 15-day supply until you or your covered family member know how you will be able to tolerate this new medication. This limitation will apply to approximately 20 specialty drugs to treat conditions such as oncology, iron toxicity, Huntington’s Chorea, and Parkinson’s. If you or a covered family member is prescribed one of these medications, you will be notified of this limitation at the time of order. Once filled, you will receive an outreach call from Express Scripts on the 8th day to assess how the medication is being tolerated. If the medication is being tolerated well, the remaining 15-day supply of the prescription will be processed so it is received before the current supply runs out. if the medication is not being tolerated well, then you will be provided with names of other medications to treat this condition to discuss with your doctor.
For 90-day supplies of other specialty medications ordered through Accredo for chronic conditions such as Multiple Sclerosis, Rheumatoid Arthritis, growth disorders, and other chronic conditions, the initial fill will be limited to a 30-day supply until that medication is reviewed to determine if the medication is being tolerated well and is being taken as prescribed. If it is, the remaining 60-day supply will be sent. Otherwise, alternative medication options will be discussed with you or your doctor instead of filling the remaining supply.
The amount you pay for the limited supply for both of these programs will be prorated so that by the time you receive the full order, you will have paid the same amount you would have paid if you had received the entire 30-day or 90-day supply at once.
These programs will help to reduce waste as well as unnecessary cost to you and to the plan when medication isn’t tolerated well.
Opioid Management Program:
We’ve all heard about the opioid crisis in the news and many of us know people personally affected by this addiction. Maritz is joining the effort to try to prevent addiction and save lives by implementing the Opioid Management Program starting 1/1/19. For new opioid pain medications prescribed, you or your covered family member will be limited to a 7-day supply of medication. This supply should be sufficient for most dental procedures and minor injuries or surgeries. Prior authorization will be required for enhanced long-acting opioids. Letters will be mailed to the home to educate members on the risks of addiction. Biodegradable disposal bags will be sent to members to dispose of unused medication to prevent opiods from being easily accessible to others. Enhanced monitoring by Express Scripts will result in point of care alerts being sent and proactive pharmacist outreach calls being made if it appears someone may be obtaining prescriptions for pain medication from multiple providers. For chronic or severe conditions where additional supplies of pain medication is needed beyond the initial 7-days, additional fills will be allowed.
Deductible Waived For Certain Preventive Drugs
The deductible will be waived for most medications taken to treat the following conditions (Referred to as Preventive Plus):
Bone Disease and Fractures
Insulin and Non-Insulin Medicines
Diabetic Supplies Including Test Strips, Syringes, Needles, and Lancets
Heart Disease and Stroke
Blood Thinner Medicines
Cholesterol Lowering Medicines
High Blood Pressure
Respiratory Syncytial Virus
These medications are taken to prevent certain medical diagnoses from developing into more serious medical conditions such as heart disease or stroke. Medications to treat these diagnoses are not covered at 100%, as the ACA required preventive medications are; however, we are permitted to waive the annual deductible for these drugs.
Preventive Medications covered at 100%
The Affordable Care Act (ACA) requires certain medications to be classified as Preventive Drugs and covered by the plan at 100% with no cost to the member, such as contraceptives, certain immunizations, prenatal vitamins, smoking cessation products, and low to moderate doses of the generic form of statin (cholesterol-lowering) drugs. However, if you take a high dose generic or brand name version of a statin medication you will pay a portion of the cost as described below.
Co-Payments and CoInsurance
The member coinsurance amount for all drugs is subject to minimum and maximum amounts after the deductible has been waived or satisfied. See the following chart below.
If your medication is on the Preventive Plus list, in addition to waiving your deductible, you will pay the applicable coinsurance percentage listed above for your medication, subject to the minimums and maximums listed above.
If your medication is not on the Preventive Plus list, you will continue to pay 100% of the cost of your medication until your annual deductible is satisfied. However, once the deductible is satisfied, your cost will be 20% (generic), 30% (preferred brands), or 40% (non-preferred brands), subject to the new minimums and maximums.
If you have prescriptions filled through Accredo (Express Scripts’ Specialty drug pharmacy), you will need to satisfy your annual deductible before the plan will pay any portion of these medications. However, Accredo may be able to obtain drug manufacturer coupons or rebates on your behalf to help you pay your portion of the cost of specialty medications. Contact Accredo to ask if you are eligible for any Copay Assistance programs they may have available.
If you do not qualify for any copay assistance programs and are struggling to pay for a full 90-day supply of home delivery medications, contact Accredo or Express Scripts to see if you are able to pay for your 90-day supply of medication in three monthly payments.
Price a Medication Option
To see your estimated out-of-pocket cost or to determine if your medications are subject to mail order requirements, step therapy rules, or require prior authorization, go to www.express-scripts.com and select the Manage Prescriptions, then Price a Medication link.
Want a Sneak Peek at your Prescription Costs Before you are enrolled?
The Express Scripts site listed below is designed to allow you to view your estimated out of pocket costs prior to your actual enrollment in the plan.
To get your estimated out-of-pocket prescription costs prior to becoming a covered member, visit: https://www.express-scripts.com/maritz
Save Even More by Contributing to Your HSA
Why not lower your costs even more by paying for your prescriptions with pre-tax dollars from your HSA? Estimate the amount you think you will be paying out of your pocket for prescriptions during the year, and also take into consideration that Maritz will be contributing $1000 per year to this account (or $2000 if you cover family members). If your estimate shows your costs will be higher than the amount Maritz contributes, make an election to contribute that additional amount into your HSA. As you get your prescriptions filled, simply show your HSA debit card at the pharmacy to pay for your medications, or use the debit card when you place your mail order with Express Scripts Home Delivery. By paying for these expenses with pre-tax dollars, you can save approximately 20 – 40%, depending on your tax bracket. Refer to the Health Savings Account section of this website for additional details.
Mail Order Requirement
The plan requires most maintenance medications to be ordered through mail order/home delivery after the first three fills at the local pharmacy. On the fourth fill at the local pharmacy, the drug will be denied, and you will be charged full price. The cost you pay will not be applied to your deductible.
Step Therapy and Prior Authorization Rules
The plan applies step therapy and prior authorization rules. This means that you must receive approval for certain medications. Step therapy rules require your doctor to prescribe a different covered medication for you or to confirm you have already tried that medication before certain drugs are covered. Prior authorization rules require your doctor to request approval from Express Scripts for certain medications by providing specific answers about your medical diagnosis and other required information.
Injectable Drugs Received in Your Doctor’s Office
For certain injectable medications for which the doctor places an individual order for you to have injected in their office, the medication must be ordered through Express-Scripts (or Accredo for specialty medications) instead of through Cigna’s pharmacy in order to be covered. If you will be receiving an injectable medication for which your doctor has to order for you to be administered in his/her office, contact Express-Scripts or Cigna to ask if this is a medication that needs to be filled through Express Scripts. If your doctor has already requested the medication through Cigna and you receive a denial stating the medication is not covered, contact Express Scripts to ask if the medication is covered if ordered through them instead.