Empire Plan Formulary changes for ’18
By DEBORAH STAYMAN
CVS Caremark, the Empire Plan Prescription Drug Program administrator, in consultation with the state agencies responsible for administering the NYs Health Insurance Program, has finalized the 2018 Empire Plan Flexible Formulary Drug List. It applies to Empire Plan enrollees for whom Medicare is not their primary drug insurance.
This list identifies the most commonly prescribed generic and brand-name drugs included on the Flexible Formulary. However, this is not a complete list of prescription drugs on the Flexible Formulary or covered under the Empire Plan.
The 2018 Empire Plan Flexible Formulary Drug List is posted on the state Department of Civil Service website at https://www.cs.ny.gov/employee-benefits. Follow the prompts to NYSHIP Online and then select “Health Benefits & Option Transfer.”
A printed copy of the Flexible Formulary will be included with the January 2018 Empire Plan At A Glance flyer, which will be mailed to enrollees’ homes at the end of 2017. To check coverage and copay information for a medication not on this list, visit https://www.empireplanrxprogram.com/ or call 1-877-7NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program.
The Flexible Formulary is updated January 1 of every year. The following changes may be made to the Flexible Formulary:
1. A prescription drug may be excluded from coverage;
2. A prescription drug may be moved from a lower-level copay to a higher-level copay (uptiers); or
3. A prescription drug may be moved from higher-level copay to a lower-level copay (downtiers).
In addition, Zomig Nasal, which was excluded in 2017, will be covered in 2018.
The following changes are effective January 1, 2018:
Drugs not covered:
Ten brand-name and generic drugs will be excluded from coverage under the Empire Plan Prescription Drug Program. No benefit will be provided for an excluded drug and the enrollee will be responsible for paying the total retail cost of the drug.
Under the terms of the Flexible Formulary side letter, therapeutically equivalent alternatives must be available for each of the excluded drugs. These therapeutically equivalent alternatives can be substituted with the expectation that the substituted drug will produce the same clinical effect and have the same general safety profile as the excluded drug.
A medical exception process is available if the preferred alternatives have been tried and failed. The prescribing physician may fax a letter of medical necessity to CVS Caremark documenting the formulary alternatives that have been tried and failed, as well as any other clinical information explaining why it is medically necessary for you to use the excluded drug.
If the medical exception is approved for the excluded drug, you will pay the Level 3 non-preferred copay. If the excluded drug is a brand-name drug with a generic equivalent available, and there’s no documentation of a treatment failure while using the generic, your out-of-pocket cost will be higher. In addition to the Level 3 non-preferred copay, you will pay the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug.
Preferred brand to non-preferred brand-name drug (Uptiers) —
CVS Caremark is moving one brand-name drug from the preferred (Level 2) midrange copay level to the non-preferred (Level 3) highest copay level. Therapeutic alternatives are available for this drug. The brand name drug moving from Level 2 to Level 3 is Cardura XL, which is used to treat benign prostatic hyperplasia (BPH). The alternatives, which may be either generic or brand-name drugs or both, are considered equally effective in treating the same condition.
Non-preferred brand to preferred brand-name drug (Downtiers) —
CVS Caremark is moving 18 brand-name drugs from the non-preferred (Level 3) highest copay level to the preferred (Level 2) mid-range copay level. The brand name drugs moving from Level 3 to Level 2.
In November, CVS Caremark sent letters to all enrollees who have filled a prescription for one of the medications that will either be excluded or is moving from the preferred Level 2 copay to the nonpreferred Level 3 copay. These letters include a list of alternative Level 1 and/or Level 2 medication options, and encourage enrollees to discuss these options with their doctors.
To contact CVS Caremark, call the Empire Plan toll-free at 877-7-NYSHIP or 877-769-7447 and press or say 4 for the Prescription Drug Program.