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Final. Conversion to 4D Pharmacy Management Program for Prescription Drug Benefit Coverage under the WMC Self-funded Medical Benefit Plans for Active Participants and Retirees pre age 65. Introduction.

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Final

Conversion to 4D Pharmacy Management Program for Prescription Drug Benefit Coverage under the WMC Self-funded Medical Benefit Plans for Active Participants and Retirees pre age 65.


Introduction
Introduction

The Pharmacy Benefit Manager for the Prescription Drug Coverage under the WMC Self-funded Medical Benefit Plan will be changed from Express Scripts to 4D Pharmacy Management Company effective February 1, 2014.

This change in the Prescription Drug Coverage to the 4D Pharmacy Program only applies to active participants and early retirees (i.e. retirees under age 65) who are covered under the WMC Self-funded Medical Plans.


4d pharmacy information
4D Pharmacy Information

4D Pharmacy is a Michigan based company located in Detroit’s suburb of Troy.

4D Pharmacy Management Company has been providing prescription drug benefit management services for over 25 years.


4d pharmacy information1
4D Pharmacy Information

4D Pharmacy maintains a comprehensive National retail pharmacy network with over 60,000 participating pharmacies across the US.

Over 2.5 million members are covered by the 4D Pharmacy Program.

4D Pharmacy has a proven track record of providing high quality service and cost effective pharmacy management services.


4d retail pharmacy network
4D Retail Pharmacy Network

Pharmacy chains participating under the 4D Network include:

Meijer Target Walmart

Rite-Aid CVS Walgreens

All of the local retail pharmacies currently utilized by WMC participants are included under the 4D Network.


Reasons for change to 4d program
Reasons for Change to 4D Program

The primary reasons for converting to the 4D Pharmacy Management Program are:

  • To improve the Overall Service Delivery levels provided to participants and dependents under the WMC prescription drug benefit coverage.

  • To realize immediate cost savings under the WMC Prescription Drug Coverage by conversion to 4D Program.


Service delivery improvements
Service Delivery Improvements

Major service improvements will be provided under the 4D Program.

A new drug delivery approach is included for

Retail Pharmacy purchase of a 90 day supply of Maintenance Generic Drugs.


Service delivery improvements1
Service Delivery Improvements

Current mandatory Mail Order requirement for long-term maintenance Generic Drugs will be eliminated.

A Voluntary Mail Order Distribution option will be retained for participants who prefer the home delivery arrangement.


Service delivery requirements
Service Delivery Requirements

A mandatory Mail Order requirement will be maintained under the 4D Program for all long-term maintenance Branded medications because this is the most cost efficient distribution method for Branded drugs.


New 4d drug coverage structure
New 4D Drug Coverage Structure

The current 3 Tier Drug Coverage Structure will be revised and expanded to a 5 Tiered Structure.

The current MEDTIPSTER Generic Drug Coverage will be included under the first level or tier of the 4D Coverage Structure.


New 4d drug coverage structure1
New 4D Drug Coverage Structure

Tier 1 of the 4D Coverage Structure will include:

  • The MEDTIPSTER Generic Drug Benefit Coverage; and,

  • A new supplemental coverage for selected Over-the-Counter (OTC) Nonprescription medications, which are prescribed by the patient’s personal physician.

    There is no copayment for the Generic or OTC Drugs obtained under the Tier 1 Coverage.


Tier 1 drug coverage
Tier 1 Drug Coverage

MEDTIPSTER Generic Drug Coverage will cover the full cost of lower priced Generic prescription medications, which cost less than $16.00 per script.

The existing Generic drug coverage provided under the MEDTIPSTER program will remain unchanged under the 4D drug plan.


Tier 1 drug coverage1
Tier 1 Drug Coverage

Selected OTC medications, which are prescribed by your physician (instead of alternate prescription medications), will be covered under Tier 1 with no cost to you or your dependents.

OTC medications must be prescribed by your attending physician in-lieu of other prescription drug treatments to qualify under the 4D Coverage.


Otc drug coverage examples
OTC Drug Coverage Examples

A separate schedule of all the OTC medications covered by the 4D Program will be forwarded to you by February 1st.

Examples are:

Respiratory- Decongestants and Antihistamines.

Cetiriline (Zyrtec/Zyrtec II)

Loratadine (Claritin/Alivert)

Loratadine(Claritin D- 24 hours)


Tier 2 under 4d drug coverage
Tier 2 Under 4D Drug Coverage

Tier 2 of the 4D Coverage Structure will cover All Other Generic medications, which are included under the new 4D Drug Formulary Schedule, except for:

  • Low cost Generic Drugs covered under the MEDTIPSTER Generic Drug Coverage of Tier 1; and,

  • High cost Non-formulary Generic Drugs, which are not included under Tier 2 of the new 4D Drug Formulary Schedule


Tier 2 drug coverage
Tier 2 Drug Coverage

Copayment levels for Formulary/Preferred Generic Drugs purchased under the Tier 2 Coverage level will depend upon the drug distribution method and the prescription supply dispensed.

$15.00 Copayment level for purchase of a 31 day supply of Formulary Generic Drugs at a participating 4D Retail Pharmacy.


Copayment levels for tier 2
Copayment Levels for Tier 2

$30.00 Copayment for purchase of a 90 day supply of long-term maintenance Formulary Generic Drugs (i.e. Preferred Generics) at a participating 4D Retail Pharmacy.


Copayment levels for tier 21
Copayment Levels for Tier 2

$30.00 Copayment for purchase of a 90 day supply of long-term maintenance Formulary Generic Drugs through the voluntary 4D Mail Order Program.

  • There is no change from the current Copayment level for the Mail Order coverage under the Express Scripts program.


Tier 3 drug coverage
Tier 3 Drug Coverage

Tier 3 coverage level will cover all Formulary Branded Prescription Drugs included under the 4D Drug Formulary Schedule.

The Formulary Branded Drugs are currently referred to as the Preferred Branded Drugs under the Express Scripts program.


Tier 3 drug coverage1
Tier 3 Drug Coverage

Copayment levels for Formulary Branded Prescription Drugs purchased under the Tier 3 Coverage will also be based on the distribution method and drug supply dispensed under the prescription.

  • A $30.00 Copayment will apply for a 31 day supply of Formulary Branded Prescription Drugs, which are purchased at a participating Retail Pharmacy.


Tier 3 drug coverage2
Tier 3 Drug Coverage

The Mail Order distribution method is required for purchase of a 90 day supply of long-term maintenance Formulary Branded prescription drugs under Tier 3 because this is the most cost efficient delivery approach for these drugs.

A $60.00 Copayment will be charged for purchase of a 90 day supply of Formulary Branded Drugs thru the 4D Mail Order program.


Tier 4 drug coverage
Tier 4 Drug Coverage

Tier 4 coverage under the 4D Drug program will include-

  • All Non-formulary Branded prescription medications (i.e. currently Non-preferred Branded drugs under the Express Scripts program); and,

  • All Non-formulary Generic prescription medications excluded from Tier 2 of the 4D Formulary Schedule.


Tier 4 drug coverage1
Tier 4 Drug Coverage

Copayment levels for both Non-formulary Generic and Non-formulary Branded drugs under Tier 4 Coverage will also be based on the drug distribution method and the drug supply dispensed.

$75. 00 Copayment for purchase of a 31 day supply of either Non-formulary Generic or Non-formulary Branded medications thru a Retail Pharmacy.


Tier 4 drug coverage2
Tier 4 Drug Coverage

The Mail Order distribution method is required for purchase of a 90 day supply of long-term maintenance Non-formulary Generic or Non-formulary Branded medications under Tier 4 coverage because this is the most cost efficient approach under the 4D program.

  • Mail Order requirement for Non-formulary drugs is retained from the Express Scripts program.


Tier 4 drug coverage3
Tier 4 Drug Coverage

A $150.00 Copayment will apply for purchase of a 90 day supply of No-nformularyGeneric orNo-nformulary Branded medications under the 4D Mail Order program.

There is no change from the current $150.00 Copayment for Mail Order purchase of Non-formulary (or Non-preferred) medications under the Express Scripts program.


Tier 5 specialty drug coverage
Tier 5 Specialty Drug Coverage

A Specialty Drug Coverage provision is being implemented under the WMC prescription drug coverage in conjunction with the new 4D Pharmacy program.

Tier 5 under the 4D program is limited to Coverage of Specialty Drugs.


Tier 5 specialty drug coverage1
Tier 5 Specialty Drug Coverage

Specialty Drugs are currently covered under the Preferred and Non-preferred Branded Drug categories of the Express Scripts program.

The Plan coverage for Specialty Drugs is being revised under the 4D program.


Tier 5 specialty drug coverage2
Tier 5 Specialty Drug Coverage

Specialty Drugs are a separate class of high priced medications, which are used for treatment of severe medical conditions- such as cancer (chemotherapy), organ transplants, multiple sclerosis, hemophilia, immune deficiencies, rheumatoid arthritis, and other comparable diseases and conditions.


Tier 5 specialty drug coverage3
Tier 5 Specialty Drug Coverage

Specialty Drugs are defined as-

  • Prescription medications, which are used for treatment of complex and rare medical conditions or diseases;

  • These medications generally require special handling and/or customized formulation;

  • These medications require closer ongoing assessment and evaluation of treatment results;

  • Specialty Drugs are not stocked by retail pharmacies;

  • Many Specialty Drugs are customized or designer type medications, which are significantly more expensive than other drug treatment programs.


Tier 5 specialty drug coverage4
Tier 5 Specialty Drug Coverage

Participant Copayment level for Specialty Drugs is 25% of the 4D discounted drug cost with a-

  • Minimum copayment of $75.00 (this is the current copayment level for Non-formulary or Non-preferred Branded Drugs); and,

  • Maximum monthly copayment level of $500.00 per participant or dependent.


Tier 5 specialty drug coverage5
Tier 5 Specialty Drug Coverage

Specialty Drugs will only be dispensed in a 31 day supply.

Specialty Drugs can only be obtained thru the Specialty Drug Pharmacy specified by 4D Pharmacy.

Specialized Mail Order service is the only delivery method available under the Specialty Drug Coverage.


Reasons for specialty drug coverage
Reasons forSpecialty Drug Coverage

Primary Reasons for including a separate coverage tier for Specialty Drugs-

  • High Cost of Specialty Drugs

  • Customization of Specialty Drug Treatment Programs for Every Patient.


Reasons for specialty drug coverage1
Reasons forSpecialty Drug Coverage

Other reasons for including a separate Specialty Drug coverage-

  • Individual case management and patient support programs.

  • The addition of the Specialty Drug coverage under the WMC Self-funded Medical Plan equalizes or balances the drug benefit coverage between active participants and retirees.


Tier 5 specialty drug coverage6
Tier 5 Specialty Drug Coverage

Prior Authorization for the Specialty Drug coverage is required in advance of any treatment

  • Prior authorization is currently required for some Specialty Drugs under the Express Scripts program.

    Specialty Drug treatment programs must be reviewed and approved in advance by 4D clinical staff to qualify for benefit coverage under the WMC Plan.


Prior authorization requirement
Prior Authorization Requirement

A Prior Authorization provision is included for specified prescription medications to ensure safe, effective and appropriate utilization of these drugs.

The 4D Prior Authorization requirement is comparable to the existing provision under the current Express Scripts Program.

This requirement ensures that participants utilize the selected medications in the most effective manner and it also supports the cost control of the Plan.


Prior authorization requirement1
Prior Authorization Requirement

The specified prescription medications, which require Prior Authorization:

  • May be addictive and subject to overuse, misuse, and/or abuse;

  • Subject to significant safety concerns;

  • Sometimes used for other treatments, which are not covered such as for cosmetic purposes; and/or

  • Extremely high cost medications.


Change in drug supply for monthly prescriptions
Change in Drug Supply for Monthly Prescriptions

The 4D Coverage includes a change in the number of days for which medications are dispensed under a monthly prescription.

Currently, a 34 day supply of drugs is dispensed for a monthly prescription under the Express Scripts program.

The monthly drug supply will be reduced to a 31 day dispensing level under the 4D Program to conform with drug industry standards.


Generic drug requirement
Generic Drug Requirement

A Generic Drug Utilization requirement is incorporated under the 4D program.

This provision requires the front-end utilization of Generic medications covered under Tiers 1 & 2 at the beginning of a drug treatment program for new prescriptions.

This requirement supports a continued focus on achieving higher generic drug utilization levels and reducing costs of the WMC Plan.

It also minimizes the participant costs as well.


Step therapy requirement
Step Therapy Requirement

The 4D program also includes a Step Therapy requirement, which is comparable to the existing Step Therapy provision under the Express Scripts program.

The 4D Step Therapy provision integrates with and complements the Generic Drug requirement.


Step therapy requirement1
Step Therapy Requirement

The purpose of the Step Therapy requirement is to initiate new drug treatment programs with the most commonly accepted and cost effective plan medications at the beginning of the treatment plan.

Any further progressions to other more costly Branded medications is based on the inability of the most common generic drug to provide positive clinical results for the medical condition.


Grandfathering for step therapy
Grandfathering for Step Therapy

Most of your existing prescriptions for Branded medications will be exempted from the application of the 4D Step Therapy requirement during the initial conversion period.

This grandfathering provision will apply for long-term maintenance Branded medications which are purchased thru the 4D Mail Order program (i.e. Well Dyne RX) during the first 90 days after February 1st.

  • Applies for both Formulary and Non-formulary Branded drugs.


Grandfathering for step therapy1
Grandfathering for Step Therapy

Under this Grandfathering approach, your physician must notify the 4D clinical staff that your current prescription for Branded drugs has already met the prior requirements of the Express Script Step Therapy provision.

A new prescription from your physician will still be necessary to obtain refills of Branded drugs thru the 4D Mail Order program under these situations.


Changes to drug formulary
Changes to Drug Formulary

A Drug Formulary is a schedule of approved prescription medications which can be obtained under a pharmacy benefit program.

  • The schedule also classifies the approved Branded medications as either Formulary (or Preferred) and Non-formulary (or Non-preferred) medications based on multiple factors including cost.

    Every pharmacy benefit manager develops and maintains their own separate Drug Formulary Schedule.


Changes to drug formulary1
Changes to Drug Formulary

There are variations in the classification of some Branded medications under the Formulary/ Preferred and Non-formulary/Non-preferred status between the 4D Pharmacy and Express Scripts Drug Formulary Schedules.


Changes to drug formulary2
Changes to Drug Formulary

Copayment levels will be increased for Branded medications which are considered to be Preferred Branded drugs under the Express Scripts Formulary but will now be reclassified as Non-formulary/Non-preferred Branded drugs under the 4D Formulary Schedule.

  • There are limited number of Branded medications which will be reclassified as Non-formulary under the 4D system.


Changes to drug formulary3
Changes to Drug Formulary

Copayments will increase from $30 to $75 for purchase of a 31 day supply of Branded drugs which are reclassified as Non-formulary (Non-preferred) under the 4D program.

Copayments will be increased from $60 to $150 for purchase of a 90 day supply of Branded drugs under the Mail Order program for the Branded drugs which are reclassified as Non-formulary (i.e. Non-preferred) under the 4D program.


Changes to drug formulary4
Changes to Drug Formulary

Other lower cost Generic medications or comparable Formulary (i.e. Preferred) Branded medications are available as alternate drug treatment programs for most of these situations.

In addition, the reverse situation will also occur where some prescriptions currently classified as Non-preferred Branded medications under the Express Scripts Formulary will be reclassified as Formulary/Preferred under the 4D Program.

  • Under these circumstances, the drug copayment levels will be reduced under the 4D program.


New prescription requirements
New Prescription Requirements

New physician prescriptions will be necessary for refill purchases of all long-term maintenance medications under the 4D Mail Order program including:

  • Maintenance Generic Drugs

  • Maintenance Formulary Branded Drugs

  • Maintenance Non-formulary Drugs (Generic & Branded)


New prescription requirements1
New Prescription Requirements

In addition, for existing prescriptions of Formulary and Non-formulary Branded medications, your physician must also notify the 4D clinical staff that the current prescription was reviewed under and authorized thru the Step Therapy requirements of the Express Script program to bypass the 4D Step Therapy provision.


New prescription requirements2
New Prescription Requirements

All prescription refills for Specialty Drugs will also require new physician prescription authorizations and must be filled thru the 4D Specialty Drug Pharmacy.


When new prescriptions are not required
When New Prescriptions Are Not Required

The only exception situations where new physician prescriptions are not required, include-

Refills of existing prescriptions for low cost Generic Drugs, previously obtained thru a Retail Pharmacy under the MEDTIPSTER Generic Drug Program.


When new prescriptions are not required1
When New Prescriptions Are Not Required

New prescriptions are not required for-

Refills of existing prescriptions for Other Generic Drugs covered under Tier Level 2 of the 4D coverage, which were previously purchased thru the same Retail Pharmacy included under the 4D Network.


When new prescriptions are not required2
When New Prescriptions Are Not Required

New prescriptions are not required for-

Refills of existing short-term prescriptions for Formulary Branded Drugs (i.e. Preferred Branded), which are covered under Tier Level 3 of 4D Coverage and were previously purchased through the same Retail Pharmacy included under the 4D pharmacy network.


Further assistance
Further Assistance

If you need further assistance, contact:

  • Elisa White at PBS 1-800-732-3412, for service issues or pharmacy benefits coverage

  • 4D Member Services 1-877-674-4026, forquestions about specific medications or formulary substitutes


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