Coming benefit changes: Maintenance medications must be filled in 90-day supplies

When the new benefit year goes into effect July 1, employees who have medical coverage through Rice must be aware of three significant changes to previous years’ plans:

• A requirement to have maintenance medication filled in 90-day supplies.
• A “Dispense as Written” provision.
• Changes to out-of-pocket costs, including a deductible for the POS plan.

Rice News spoke with Susan Prochazka, Rice’s new director of benefits, to explain the changes and will focus on one change each week as the new benefit year begins.

What is the requirement to have maintenance medications filled in 90-day supplies?

Plan participants who take a maintenance medication will be required to fill those prescriptions in a 90-day supply either through Rice’s mail-order pharmacy (Orchard Pharmacy, which will soon be renamed EnvisionMail Pharmacy) or through a retail pharmacy that participates in the EnvisionRx retail network. Participating pharmacies can be found online at www.envisionrx.com, and include most major chains in the United States such as CVS, Walgreens, Kroger, HEB, Wal-Mart, Target and many others.

What is a maintenance medication? 

Maintenance drugs are medications prescribed for chronic, long-term conditions and are taken on a regular, recurring basis. Examples of chronic conditions that may require maintenance drugs are high blood pressure, high cholesterol and diabetes.

Why is Rice doing this?

This change was discussed with the Benefits Committee. It is less expensive to produce one 90-day-supply prescription (pharmacy services, packaging, invoicing, unit cost, etc.) than to produce three 30-day supplies, so the medical plan pays less and you pay less. Since these medications are taken continuously and are available both through retail and mail-order pharmacies, it is one way to contain rising expenses without causing additional costs or effort to the patient. Many medical plans have adopted this provision.

Now that the option to fill a 90-day supply at a retail pharmacy is available, it offers most of the cost savings of mail order and provides the convenience of retail. The copay for 90-day mail order and retail will be the same — two-and-a-half times the cost of a 30-day supply.

How will I know if I am required to get a 90-day supply?

Your pharmacist will inform you when the plan requires you to purchase your maintenance medication in 90-day increments.

Do I have to have the 90-day supply filled immediately upon July 1? Do I need to do anything different than I usually do?

After July 1, for your first refill of a maintenance medication that you are currently using, you will need to obtain a 90-day prescription from your doctor. For new medications, for your convenience, you can choose to receive your first two months of maintenance medication in 30-day fills at any contracted retail store. This will give you and your physician an opportunity to ensure the medication is appropriate for you in dosage and type before filling for a larger amount. After the second fill of a new medication, you will be required to use either the EnvisionMail Pharmacy or an EnvisionRx retail network pharmacy. Participating pharmacies can be found online at www.envisionrx.com.

How much will a 90-day supply cost?

Copays for 90-day prescriptions will be $25 for generic, $100 for brand-name and $150 for nonformulary drugs and can be obtained at both retail outlets and through mail order. A 90-day supply of prescriptions is actually less than three 30-day supplies of the same medicine, so this provision saves both plan participants and Rice money.

Will certain drugs for chronic conditions still be covered at $0 copays even though they are purchased for 90 days?

As part of the plan’s effort to help employees manage certain long-term medical conditions, certain generic drugs used to control high blood pressure, cholesterol, diabetes and asthma will continue to be available for the $0 copay.

What if I don’t do the 90-day refills for my maintenance medications?

Plan participants who do not follow this procedure will be responsible for the full cost of the medication. This provision is effective July 1. This means that you will need to get a 90-day prescription from your doctor for all currently used maintenance medications to have them refilled after July 1. For new medications after July 1, you can get them filled up to two times in a 30-day supply, but after that you will need a 90-day prescription.

What should I do to receive a 90-day medication fill?

To start receiving a 90-day supply of medication at one of the participating pharmacies, you will need to

• Ask your physician to write your prescription for a 90-day supply with the appropriate number of refills. Do this now to ensure you won’t be inconvenienced with any delays. Often your doctor will call in the prescription directly to your pharmacy, so be sure to have the phone number to your pharmacy ready when you call your doctor.
• Either take your prescription to any participating retail pharmacy or use the mail- order services through EnvisionMail (formerly Orchard Pharmaceutical) to receive your prescriptions.

What do I need to do if I have my maintenance medications already on auto-refill through my pharmacy?

If the auto-refill is for a 90-day supply, you don’t need to do anything. If it is for a 30-day supply, it will be denied for the first re-fill after July 1, and you will need to obtain a 90-day-supply prescription from your doctor.

If I already get my prescriptions through Orchard, do I need to do anything?

No.

Do I have to contact each doctor who prescribes my medicine or can I just contact my pharmacy?

You will need to contact each prescriber to obtain a new 90-day-supply prescription.

Is there a list of maintenance medications or somewhere online employees can input the drug name to see if it falls into this category?

No, there is not a list; however, your pharmacist will be able to tell you if each is considered a maintenance medication when the prescription is run through the claims system. In general, maintenance medications are taken on a long-term basis for chronic or long-term conditions such as high blood pressure, cholesterol and diabetes. They do not include medications, such as antibiotics, taken for acute illnesses.

Benefits-eligible employees who have questions about Rice’s health and welfare plans can contact the benefits team at benefits@rice.edu or 713-348-2363.

“Most important is that you shouldn’t wait until June 30 to request new prescriptions from your doctors,” Prochazka said. “We urge you to reach out to your doctor now to prepare for this change. We don’t want you to experience any delay in getting your prescription filled because medication adherence is an important part of your treatment regimen.”