FAQ: Preferred pharmacy supplier changes for Specialty and Mail order medications

Transcription

1 FAQ: Preferred pharmacy supplier changes for Specialty and Mail order medications Table of Contents BACKGROUND... 2 OVERALL TALKING POINTS... 2 GENERAL FAQ... 3 SPECIALTY MEDICATIONS... 5 MAIL ORDER... 8 ASO GROUPS IDAHO GROUPS AND MEMBERS COMMUNICATIONS Optional Group Letter Member Letter Specialty Medications Member Letter Mail Order MAIL ORDER FORM BRIOVARX EXCLUSIVE MEDICATIONS Page 1

2 BACKGROUND The rising cost of prescription drugs threatens accessibility and affordability for the people who need them. In the next five years, spending on specialty medications is expected to rise 15 to 20 percent per year. And by 2020, nearly half of all drug spend in the U.S. will be for specialty medications. OmedaRx has decided to move fulfillment of specialty drugs to BriovaRx and fulfillment of mail order drugs to OptumRx Home Delivery due to significant supplier discounts offered for comparable and in some cases superior care and service. ASO groups will also see savings from this change, as the Average Wholesale Price discount realized will increase from about 14 percent to 19 percent for specialty drug fulfillment. Copays for individual members will not change. The cost impact to members who have coinsurance varies by individual drug and is not predictable; this is the case today with members using any specialty pharmacy. Specialty Drugs: Specialty medications treat serious health conditions such as cancer and rheumatoid arthritis. They are complex and expensive, and typically require special handling, administration or monitoring. Many specialty medications will be required to be filled by Briova Rx these are called BriovaRx Exclusive medications. Transitioning members to BriovaRx will be carefully orchestrated between Asuris, the member s current specialty pharmacy and BriovaRx to ensure the member s treatment is not interrupted. The priority is to ensure that members taking specialty medications have a smooth and easy transition to BriovaRx. Member Impact: About 114 Asuris members are currently taking BriovaRx Exclusive medications and will be transitioned to BriovaRx and 415 members are using Walgreens mail order service and will be transitioned to OptumRx Home Delivery. Implementation dates: March 1, 2016, for BriovaRx Exclusive medications; April 1, 2016, for Mail Order Medications OVERALL TALKING POINTS As pharmacy costs continue to rise to unsustainable levels, OmedaRx works hard with our suppliers to ensure our members receive high-quality, cost-effective care based on nationally recognized standards and evidence-based guidelines. Quality is our first priority, and when we can negotiate lower costs for comparable care, it benefits everyone. Specialty medication transition: Moving specialty medications to BriovaRx will help us ensure members taking specialty medications get the support they need. BriovaRx focuses exclusively on supporting patients on specialty medications with personalized care, 24/7 access to clinical experts, patient education, fill reminders, free home delivery, and more. Page 2

3 Not all specialty medications are affected. Some are exclusive to specific pharmacies, some specialty medications are covered under the medical benefit, and in some cases, the member s therapy will continue with another pharmacy to ensure continuity of care. BriovaRx care managers will work with members one-on-one to accommodate their needs based on the specialty medications they take. Members will receive personalized support through the transfer to BriovaRx and throughout their therapy. Mail order transition: Members will receive notice of the change approximately 60 days in advance with instructions on how to register with OptumRx Home Delivery for their prescription needs. Walgreens will initiate a file transfer on April 1 for those prescriptions that can be transferred. Walgreens is working closely with us throughout these transitions to minimize disruption to members and they continue to be a strong partner for us as an in-network provider for regular prescription coverage and Limited Distribution medications. GENERAL FAQ Which lines of business are affected by these changes? ASO and Commercial plans with Specialty Select All Individual on and off-exchange plans (Specialty Select is embedded in these plans) All Fully Insured plans that do not have Specialty Select in Washington, Utah and Oregon (Idaho Fully Insured Plans will be moved on a case-by-case basis) The project team with work with Sales AEs to move ASO plans that do not have Specialty Select on a case-by-case basis Members of Washington and Idaho PACE groups who use Walgreens mail order service will be moved to OptumRx Home Delivery on April 1. Walgreens will not provide in-network mail order services as of April 1. The specialty transition for members of Washington and Idaho PACE groups will be handled on a case-by-case basis, working closely with Sales. These groups do not have Specialty Select and cannot be forced to move their members to BriovaRx for Specialty, but we can reach out to them and share the advantages of moving. Why make the changes? The rising costs of prescription drugs is unsustainable. Over the next five years, spending on specialty drugs is expected to rise 15 to 20 percent per year. The costs of many commonly used drugs are also going up even though manufacturers have done nothing to improve them. Health insurance covers most of the costs, but higher prices lead to higher out-ofpocket costs for members and adds to the cost of health insurance overall. Page 3

4 Quality is our first priority. If we can negotiate lower costs for comparable care, it benefits everyone. We have negotiated favorable rates with our supplier for OptumRx Home Delivery and BriovaRx for specialty medications, which helps us contain costs and create a more economically sustainable health care system for all. Are there performance guarantees with these suppliers? Yes. Performance guarantees for both suppliers are: 95% first call resolution Toll-free 24/7/365 access to a pharmacist 4% or less phone abandonment 85% or more of calls answered within 30 seconds 95% of prescriptions shipped within 5 business days What is your plan for managing these transitions or handling issues as they arise? We have a large cross-functional team meeting regularly throughout implementation. Will members pay less for their prescriptions? Contracted rates with OptumRx Home Delivery and BriovaRx are based on aggregated amounts and not on individual medications, so the cost impact to members who have a coinsurance varies by individual drug and is not predictable. This is the case today with Walgreens or any other specialty pharmacy. Copays will stay the same. Will Walgreens still be considered an in-network pharmacy for our members? Yes. Walgreens will continue to be an in-network provider for routine, walk-in prescriptions, and specialty medications covered under the medical plan (typically injected or infused by a health care professional). Walgreens also has limited distribution rights on certain specialty medications. A few members who are enrolled in specialty disease management programs will continue with Walgreens until their treatment is completed. What about members using Site of Care infusion services through OptionCare? This transition does not include infused medications. Site of Care services will stay with OptionCare. Will there be any change in the pre-authorization process? No. If a member has a pre-authorization in place, it will stay in place with the new provider. Will all existing overrides in place in the claims system stay in place? Example. Member is allowed to fill a specialty Rx through mail order instead of Specialty. Existing overrides should stay in place. Will prescriptions be transferred automatically? Yes. Affected members currently using BriovaRx Exclusive medications will move to BriovaRx by March 1. The transition will be facilitated for each member by BriovaRx Page 4

5 staff, who will help members register with BriovaRx for payment and delivery information. Members may also register at the BriovaRx website, briovarx.com/newpatient or by calling 855-4BRIOVA ( ). All mail order members will be transferred to OptumRx Home Delivery on April 1. Members will need to register with OptumRx Home Delivery after April 1 for payment and delivery information. Directions and a mail order registration form will be included in the member letter. Will personal payment information (credit card) transfer from current exclusive suppliers? No. Payment information cannot be transferred. Will social security numbers be transferred to the new suppliers? No. Will members receive any change in the medications they take? Members will continue to receive the same medications. There are differences in drug manufacturers that can result in medications being different sizes, shapes or colors. So, while it will be the same drug, in some cases it may look different. Where are the distribution centers for specialty and mail-order medications? For specialty medications, the distribution center is Las Vegas, Nevada. For mail order, it s Avon Lake, Ohio, and Las Vegas, Nevada. Does either supplier use off-shore resources for any customer-facing services (such as call centers or fulfillment sites)? No. SPECIALTY MEDICATIONS Who is BriovaRx? BriovaRx is a specialty pharmacy that focuses exclusively on patients taking specialty medications for complex conditions. For more than 15 years, BriovaRx s work has been to ensure that all patients get the expert, personalized support they need to manage their complex conditions. BriovaRx is accredited by URAC, an independent, nonprofit leader in promoting health care quality. BriovaRx uses a unique onboarding process that integrates videochat capabilities for members new to specialty medications to help them get started. They also offer extensive videos and instructions on their website for member self-service. How many members will be affected by this change? About 114 Asuris members (excluding Medicare) are currently taking BriovaRx Exclusive medications. Page 5

6 Are all specialty medications required to be filled by BriovaRx? No. The contract with BriovaRx stipulates that certain specialty drugs will be filled exclusively at BriovaRx (BriovaRx Exclusive). BriovaRx Exclusive drugs must be filled at BriovaRx or members may face paying full price. This is consistent with our current Specialty Select practices. HIV medications and low-cost immunosuppressants are not considered BriovaRx Exclusive. There are also some Limited Distribution drugs that BriovaRx does not have access to. Members taking these drugs may continue using their current pharmacy. The final list of BriovaRx Exclusive medications will be available within the next week and will be included in a future Sales Quick Takes. What about groups that have added Specialty Select effective 1/1/16? These patients will be transitioned to BriovaRx prior to March 1, in an effort to reduce the risk of multiple pharmacy switches. What will the member s experience be during the transition to BriovaRx? Transitioning members to BriovaRx will be carefully orchestrated between Asuris, the member s current pharmacy and BriovaRx to ensure treatment is not interrupted. Asuris will send affected members a letter announcing the change. This will be followed by a phone call by a BriovaRx specialist who will help members transfer their prescriptions, if needed, and enroll in BriovaRx s system. BriovaRx focuses exclusively on supporting patients who take specialty medications. Briova s specially trained staff will work one-on-one with each member and their doctor to transfer their prescription. Specialists stay in contact with members throughout treatment. BriovaRx offers personalized care, 24/7 access to clinical experts, patient education, fill reminders, and home delivery. BriovaRx s commitment to members is to: Work as part of the member s care team with their health care provider Support members with counseling and information about medications Assist members with medication self-administration training Communicate with members doctors regarding follow up, as needed Help members enroll in Copay Assistance Program, when needed Call members each month to coordinate the refill shipment of their medication Provide 24-hour emergency pharmacy services over the phone Will phone calls placed to specialty members be a person or an automated call? Automated calls are used to get members on the line. Once on the line, members are transferred to a BriovaRx patient are coordinator. Will BriovaRx allow a first fill of a specialty medication at a retail pharmacy before moving to BriovaRx? Yes. Page 6

7 How do members get their medications from BriovaRx? BriovaRx coordinates the delivery of medication with each member every month. Medications can be sent directly to a member s home, work, or doctor s office. Experienced shippers like UPS ensure that members packages are carefully shipped. If a medication requires special handling, like refrigeration, BriovaRx packages and ships it accordingly at no extra cost. How does BriovaRX manage concerns about package theft? BriovaRx manages member concerns associated with package theft on a case-by-case basis to ensure an appropriate resolution that allows the member continued access to their medications without concern. Will members who cannot afford their specialty medications continue to have access to financial assistance? Yes. BriovaRx has reimbursement specialists who can help patients find the right patient assistance programs for them, if one exists. BriovaRx will work one-on-one with each member to accommodate their needs during the initial outreach call. How does this affect members currently receiving financial assistance through Walgreens or the manufacturer? BriovaRx s patient care coordinators will ask each member they contact if they have been receiving any financial assistance. In almost all cases, BriovaRx can continue to provide that same assistance. How do members pay for their specialty medications? BriovaRx accepts check-by-phone, money orders, and most major credit cards like MasterCard, Visa, Discover, and American Express. Walgreens has several customized programs for specific specialty medications. Will BriovaRx be able to continue with these programs? Yes, though members in some existing programs may transition over time, after their therapy is completed or they are stable taking the medication. Oncology cycle management and split-fill programs. Members in this program are on certain oncology medications for 15 days at a time to assess tolerability and mitigate the risk of waste. If after three months of therapy, members can tolerate a medication, they can receive 30-day supplies for the duration of therapy. We will delay moving any member in the split-fill program to BriovaRx until they have completed the first three months of therapy, can tolerate 30 days of therapy, and receive a 30-day supply of medication. Newly diagnosed members will use BriovaRx s split-fill program for Oncology medications. Hepatitis C drugs. These drugs are generally administered over a 12-week period. We will not move members currently in therapy. Newly diagnosed members will use BriovaRx s program for Hepatitis C medications. Page 7

8 Some specialty pharmacies like Walgreens have exclusive rights to some drugs that BriovaRx does not. What must a member do if he or she is taking a Walgreens Limited Distribution drug? Some drug manufacturers supply their medications only through a single pharmacy. These are known as Limited Distribution drugs. We estimate that less than 1 percent of members are currently taking Limited Distribution drugs. These members may continue to receive these drugs from Walgreens or their current specialty pharmacy provider. Does BriovaRx have the same high level of member service that we enjoy today? Yes. BriovaRx regularly conducts member satisfaction surveys. The Voice of the Customer survey conducted monthly shows satisfaction rates exceeding 90 percent. MAIL ORDER Who is OptumRx Home Delivery? OptumRx Home Delivery is a leader in the pharmacy benefit management (PBM) industry and serves more than 13.5 million people through its award-winning mail order pharmacy and national network of more than 67,000 community pharmacies. How many members will be affected by this change? About 415 Asuris members are using Walgreens mail order service. What will the member experience be during the transition? Prescriptions for members currently using Walgreens mail order service will automatically transfer to OptumRx on April 1. Members will receive a letter about 60 days in advance that includes instructions for registering with OptumRx and ordering a new prescription if necessary. An OptumRx Home Delivery registration form will also be included with the member letter. How do members sign up for mail order if they don t use a computer? Members can also register by phone or mail. Will there be a registration form enclosed in the letter? Yes. What happens if members don t make the call or reach out? If the member s prescription is automatically transferred from Walgreens Mail Service Pharmacy, they will automatically be registered in the OptumRx system. However, their shipping address and payment method will be needed prior to filling and sending the prescription. Member Services at Asuris or OptumRx can help the member register and OptumRx can expedite shipping for a fee. How are we handling members who are taking controlled substances? Controlled substances cannot be transferred and members will need to get a new prescription. This is explained in the letter to give members advance time to prepare. Page 8

9 How are we handling members whose prescriptions have expired? Expired prescriptions cannot be transferred and members will need to get a new prescription. This is explained in the letter to give members advance time to prepare. For those members who get their first mail order prescription between Jan.- March, how will they be transitioned to OptumRx? The file used to automatically transfer mail order prescriptions will be pulled in late March. Another file will be pulled in mid-april to capture members who fill mail order prescriptions during the transition period. What is the average turnaround time for OptumRx mail order? How quickly will members get their meds? The prescription will be mailed 2-3 days after receipt, with the member receiving the prescriptions within days. Standard shipping is free. Members can elect express delivery for a fee. Are any members moving earlier than 4/1? No. If a member runs out of medications and calls OptumRx Home Delivery, what happens? OptumRx s customer service team will work with the member to get a new prescription from the member s doctor. In some cases, new prescriptions can be sent electronically. OptumRx can expedite shipping, for a fee. Are Idaho members required to move to OptumRx Home Delivery? We will initially move all members currently using Walgreens Mail Service Pharmacy, Idaho members included. However, Idaho members may choose another supplier at network rates if the supplier agrees to our terms and conditions. Otherwise, choosing an out-of-network provider may result in higher out-of-pocket costs for the member. If the member is using the automatic refill option at Walgreens, will that transfer to OptumRx? No. Members will need to reenroll in the automatic refill program for maintenance medications. They can do so through the website, app, or via phone. Does OptumRx review all prescriptions to see if a less-expensive generic equivalent is available? Yes. In many cases, this is mandated by state law. Page 9

10 ASO GROUPS Will ASO groups benefit from this change? ASO groups who use Specialty Select will see savings in their specialty medication spend as a result of this change. ASO groups who do not use Specialty Select may see savings, depending on their utilization rates through BriovaRx. Will ASO groups be allowed a transition period? Yes. The implementation team is working closely with Sales AEs to move ASO groups to the specialty provider on a case-bycase basis. Do you have estimated cost savings due to supplier switch we can share with groups? We can calculate savings for each group based on past utilization. Contact OmedaRx_help@OmedaRx.com for more information. IDAHO GROUPS AND MEMBERS Will Idaho members be included? Yes. Idaho members will be affected by these changes. We are working closely with Sales AEs to move Idaho members in groups that have the Specialty Select program. This includes ASO and Fully Insured groups with Specialty Select and all Individual on and off-exchange members. The implementation team is working closely with Idaho AEs to move Fully Insured and ASO groups that currently do not have Specialty Select. Due to the Idaho Any Willing Provider law, members may opt out of the supplier changes at network rates if the supplier agrees to our terms and conditions. Given the any willing provider law in Idaho, can we move members who have Specialty Select under Fully Insured, Individual and ASO plans? Yes. Members covered under Specialty Select can be moved to BriovaRx. However, state law allows these members to use a different provider at network rates if the provider agrees to our terms and conditions. Otherwise, they may pay more out of pocket if they choose an out-of-network provider that does not agree to our terms and conditions. Because ASO groups are governed by federal law, they may opt out of the Idaho any willing provider law and force their members to BriovaRx exclusively. Does moving to BriovaRx violate our contracts with groups? No. Contracts do not specify which specialty pharmacy is exclusive. What does the any willing provider law allow members to do? Idaho state law dictates that we cannot restrict access to providers. However, if a member chooses an out-of-network provider, it could affect what they pay (coinsurance). Copay remains the same. ASO groups may opt out of the state any willing provider law. Page 10

11 What happens if a member chooses an out-of-network provider for their specialty medication? Out-of-network providers are treated as in-network if they accept our terms and conditions. The member would learn if they accept our terms and conditions at the point of service in the pharmacy. Page 11

12 COMMUNICATIONS Optional Group Letter Health Plan Logo <Group administrator first name> <Group administrator last name> Address 1 Address 2 Dear <group administrator first name>, Subject: Changes to preferred specialty and mail order pharmacy providers As pharmacy costs continue to rise, we work hard to make sure our members receive access to high-quality, cost-effective care based on nationally recognized standards and evidence-based guidelines. Quality is our first priority, and when we can negotiate lower costs for comparable care, it benefits everyone. To that end, we are making the following changes to our preferred pharmacy network: Effective March 1, 2016, BriovaRx will be our preferred Specialty Pharmacy, replacing Walgreens Effective April 1, 2016, OptumRx Home Delivery will be our preferred mail-order pharmacy, replacing Walgreens Walgreens continues to be an in-network provider and a valuable partner for routine, walk-in prescription needs. Outreach for members taking specialty medications Specialty medications treat serious health conditions such as cancer and rheumatoid arthritis. They are complex and expensive, and typically require special handling, administration or monitoring. Effective March 1, 2016, members will need to fill most of their specialty medications at BriovaRx. There are some exceptions and BriovaRx s patient care coordinators will work with members one-on-one to transfer prescriptions if needed. BriovaRx exclusively serves patients taking specialty medications. For more than 15 years, BriovaRx s work has been to ensure every patient gets the expert, personalized support they need to manage their complex conditions. BriovaRx is accredited by URAC, an independent, nonprofit leader in promoting health care quality. Members currently taking specialty medications will receive personalized support through their transition to BriovaRx. Your health plan will send a letter to members introducing BriovaRx, which will be followed by a phone call from BriovaRx. BriovaRx s specially trained staff will work with each member and their doctor to transfer prescriptions if needed and touch base with members throughout treatment. Outreach for members using mail order pharmacy services Page 12

13 Effective April 1, OptumRx Home Delivery will be our preferred mail order pharmacy. Your health plan will send members a letter at least 60 days in advance with instructions on how to register with OptumRx Home Delivery for their prescriptions. Our supplier for OptumRx Home Delivery is URAC accredited and is a leader in the pharmacy benefit management (PBM) industry. They serve more than 13.5 million people through their mail order pharmacy and national network of more than 67,000 community pharmacies. Our priority is to ensure that members taking specialty medications and those using mail order prescription services have a smooth and easy transition to our new suppliers. If you have any questions about these changes, please contact me at (xxx) xxx-xxxx. Sincerely, Member Letter Specialty Medications Health Plan Logo <Mbr first name> <Mbr last name> <Mbr Address 1> <Mbr City>, <Mbr State> <Mbr Zip 1> Dear <Mbr first name>, Subject: Important news about a change to your preferred specialty medication pharmacy Thank you for being a [health plan] member. We appreciate your business and work hard with our vendors to make sure you continue to have high-quality, cost-effective care. Our records show you have filled a prescription for a medication that is considered a specialty medication under your 2016 health benefits plan. We are writing to introduce you to our Specialty Pharmacy provider, BriovaRx. On March 1, 2016, most specialty medications must be filled by BriovaRx. There are some exceptions. A BriovaRx patient-care coordinator will call you soon to discuss your specialty medication needs, if your medications must be transferred to BriovaRx, and help transfer them if needed. Your medications will be delivered to the location of your choice at the same in-network costsharing you pay today. Caring for patients who take specialty medications is BriovaRx s business. Their pharmacists are highly trained and they understand your special therapy needs. And BriovaRx s staff is available 24 hours a day, seven days a week, to help you with any support you may need. You don t have to wait for a call. If you want to get started right away, call BriovaRx at (855) 4BRIOVA or (855) and a care coordinator will be happy to help you transfer your prescription(s) immediately. Page 13

14 If you have any questions about your benefits plan, please call Member Services at the number listed on the back of your member ID card. We re here to help. Sincerely, Penny Garrett Director, Member Services Member Letter Mail Order Health Plan Logo Date </First Name> <Last Name> <Address> <Address> Dear <First Name>: Subject: Mail order prescription vendor changes from Walgreens to OptumRx on April 1, 2016 We are writing today to let you know that on April 1, 2016, our new preferred mail order prescription pharmacy vendor will change from Walgreens Mail Service Pharmacy to OptumRx Home Delivery. OptumRx Home Delivery is a leader in the pharmacy benefit management (PBM) industry and serves millions of people through its award-winning mail order pharmacy. We are working closely with Walgreens and OptumRx to make this an easy change for you. What you need to know: On April 1, 2016, any active prescription with Walgreens Mail Service Pharmacy that has one or more refills remaining will automatically transfer to OptumRx Home Delivery. Controlled substances (such as Valium, Vicodin, Ritalin and others) cannot be transferred, by law. Expired prescriptions cannot be transferred, as a current prescription is needed for refills. Compound medications cannot be transferred due to the nature of the medication. What you need to do now: 1. Be prepared so you do not miss a dose during the transfer: Work with your current pharmacy to make sure you have about three weeks worth of medication on April 1 to get you through the transition period. Page 14

15 2. If you are taking a controlled substance, get a new prescription. You will need a new prescription from your doctor to send to OptumRx Home Delivery using the enclosed New Prescription Mail Order form. 3. Check your number of refills remaining. Prescriptions must show one or more refills to transfer. If they do not, call your doctor to get a new prescription. 4. If you are using a compound medication, you may need to find a new pharmacy. OptumRx cannot fill compound medications. Walgreens remains an in-network provider. You can also fill your compound medication at other retail compound pharmacies. What to do after April 1: Register with OptumRx on or after April 1 with your preferred shipping address and payment information. You can register in one of the following ways: 1. You may register on or after April 1. Visit asuris.com/pharmacy to register. 2. By mail, using the enclosed New Prescription Mail Order form. 3. By phone after April 1 by calling Member Services at the number listed on your member ID card. If you have questions about current prescriptions, contact Walgreens Mail Service Pharmacy at (888) For questions about mail order services on or after April 1, or for questions about your health plan benefits, call Member Services at the number listed on your member ID card. We re here to help. Sincerely, Penny Garrett Director, Member Services Page 15

16 MAIL ORDER FORM Page 16

17 BRIOVARX EXCLUSIVE MEDICATIONS Page 17

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