Document 6600591

Benefit Services
East H ill Office Build ing, 1st floor
395 Pine Tree Road
Ithaca, NY 14850
t. 607.255.3936
f. 607.255.6873
e. [email protected] u
hr.cornell.ed u/ benefits
Questions and Answers about the Endowed Prescription
Drug Plan Through Express Scripts (ES) Effective
1/1/2015
Who is ES?
ES is one of the most experienced full-service pharmacy benefit managers (PBM)
in the nation. ES contracts with pharmaceutical manufacturing companies and
pharmacies to make sure that we are receiving the most competitive prices and
discounts for prescription drugs, helping both the university and our faculty, staff
and retirees save on prescription drug costs.
What other advantages are there to ES?
ES has a broad network that includes more than 68,000 pharmacies nationwide, a
convenient Home Delivery service for easy ordering of refills, a full complement
of internet services at www.express-scripts.com, sophisticated drug use checks
and balances, a ’round-the-clock clinical hotline for patients, and well-trained
Member Service representatives.
Who will be covered by the ES prescription drug program?
If you are a participant in any of the endowed health care plans administered by
Aetna, you will be covered by the ES prescription drug program.
Will I receive an ES ID card for use in purchasing prescription drugs at
participating pharmacies?
Once you complete your Aetna health plan enrollment in Workday and have had a
health insurance deduction taken from your paycheck, Express Scripts will mail
an ES ID card in about 14 days. You will need to use your ES ID card for all your
prescription drug purchases. Aetna will not be authorized to service your claims at
the pharmacy counter or by mail order. You need to use your Aetna ID card to
receive all other medical services.
How do I purchase my prescription at a participating retail pharmacy when
I do not yet have my ES ID card to present to the local pharmacist?
You pay the applicable copay if you provide the following information to the
pharmacist: your Employee ID number and the RX Group Number which is
“Cornell.” Be sure to tell the pharmacist that ES is the insurer.
Can I print a temporary ES ID card?
Yes, once a health insurance deduction has been taken from your paycheck, you
should be able to access the Express Scripts website and register because your
eligibility will be in the Express Script’s system. As a word of caution, there
may be a little bit of a time delay between when your eligibility is in ESI’s system
Cornell University is an equ al opportu nity affirm ative action ed u cator and em ployer.
ES Q&A Effective 1/1/2015
Revised 10/27/14
Page 2 of 9
and the deduction is taken from your paycheck. You can print a temporary
prescription drug ID card and use it.
Members can print a temporary insurance card by registering with ES online and
following these instructions:
 https://www.express-scripts.com/
 In the header click on “Health and Benefits Information”
 Select “Getting Started”
 Go to “Access your Benefits” at the bottom of the page
o Click on hyper link “View your copayments and plan information”
 On the right column is a box “Print a temporary insurance card”, click on
it
 Here you can select the button “print the card”
How much do I have to pay if I purchase a prescription at a participating
retail pharmacy but I do not have my ES ID and they will not accept the
above information?
You will need to pay for the prescription and then submit a claim to ES for
reimbursement. You will be reimbursed at 100% less the applicable copay.
How much do I have to pay if I purchase a prescription at a nonparticipating retail pharmacy?
You will pay $10 more than if you purchased your prescription at a participating
retail pharmacy.
What pharmacies are participating in ES’s Preferred Retail Pharmacy
Network?
Preferred Participating Pharmacies: Kinney, Rite Aid, Target, Green Street
Pharmacy, Quinlan’s, Walmart, Wegmans, and Cornell’s Gannett Student Health
Center. You can call ES’s Member Services at (800) 230-0508 or log on to
www.express-scripts.com to find out whether a particular pharmacy is
participating.
How much will I pay for my medications at a local Preferred Retail
Pharmacy?
You will pay $5 for generics, $30 for drugs on ES’s formulary and $50 for drugs
not on ES’s formulary (and not excluded from the formulary). Cornell pays the
rest. A formulary is a list of approved drugs.
Note: if you are enrolled in the HSA Plan administered by Aetna, you must first
meet the applicable deductible. For medications that are considered preventive
and are listed on the “ES Preventive Drug List for the HSA Plan” medications list,
you pay the applicable copay. The deductible does not apply. Refer to
http://hr.cornell.edu/benefits/health/hsa.html to review ES’s Preventive Drug List.
2
ES Q&A Effective 1/1/2015
Revised 10/27/14
Page 3 of 9
What Pharmacies do not participate in the Preferred Retail Pharmacy
Network?
Non-Preferred Pharmacies: CVS, Walgreen’s (including the Duane Reed chain in
NYC) and Tops Food Markets.
You can call ES to see if a pharmacy is participating in the Preferred Retail
Pharmacy Network by calling ES at 800-230-0508.
How much will I pay for my medications from a pharmacy not participating
in the Preferred Retail Pharmacy Network?
You will pay an additional $10 copay. Generics $15, $40 for drugs on formulary
and $60 for drugs not on the formulary (and not excluded on the formulary).
Why does my copay change at retail or through Home Delivery when my
medication has not changed?
There are several reasons your copay may change when you fill a prescription:
 ES is constantly evaluating new drugs that gain federal Food and Drug
Administration (FDA) approval for sale. Brand name drugs may lose their
patent protection and one or more generic drugs may be approved to take
the place of the brand name. When generics become available, the older
brand name drug may move to the third Tier of the drug listing with a
higher copayment. This is to provide an incentive to patients to try the
generic at greatly reduced cost. Generics contain the same active
ingredients as brand-name drugs, work the same way, and must meet the
same rigid FDA standards for quality, strength and purity. The pharmacist
may call your doctor to see if it is fine to switch to the generic or the
patient may need to make an appointment with the doctor to discuss all the
options.
 If there are multiple brand name drugs that are clinically equivalent, the
financial deal the PBM makes with the manufacturer of one of the drugs
may be much more favorable than the other(s). Thus, ES puts the best
financial deal onto the preferred Tier 2 and the less financially
advantageous deal on the non-preferred Tier 3 to save you and the health
plan money. When you re-fill your prescription, you will notice the
change in copay between Tiers 2 and 3 and may want to talk with your
doctor to see if the Tier 2 drug can be substituted for the Tier 3 drug or
even a generic to save you money.
 At least annually, ES will review contracts with a number of
manufacturers to seek out better deals for you and your health plan. ES
offers drug manufacturers a place on their preferred list if the drug
companies will lower prices. Since ES represents millions of consumers in
many health plans, they have a very powerful argument for drug discounts
of various kinds. Drug manufacturers then compete for a spot on the
preferred listing to serve you. Usually, on January 1, there are a handful of
medications that move from the third Tier to the second Tier and another
group that moves from the second Tier to the third. Some medications will
3
ES Q&A Effective 1/1/2015
Revised 10/27/14
Page 4 of 9
move from the formulary (third Tier) to being excluded because clinically
equivalent medications are available on the other Tiers. A coverage review
(appeal) can be requested. Refer to page 5: Coverage Review section.
These changes can be disruptive to the affected individuals but the clinical
evidence shows that the competing drugs are equivalent in their
therapeutic effects. Unlike drugs that are not put into competition for
discounting against one another.
 Basically, most FDA approved drugs are covered under Cornell’s health
plans but a few are excluded from the formulary. We use the market
power of ES to get the best possible pricing for you in terms of the copays
you owe as well as the health plan premiums you pay to support the
plan. If your copay changes, you and your doctor always have the right to
appeal the higher copay decision if the lower cost brand name drug or
generic drug is not appropriate for your treatment or the drug is excluded
from the formulary and not covered. In most cases, when your doctor
certifies that the medication you are using is the only one shown to be
effective in your case, then ES relaxes its rules and honors the doctor’s
request.
 You can find out if your current or newly prescribed medication is on the
Express Scripts (ES) Formulary list by calling Express Script’s Member
Services at (800) 230-0508. Member Services will be able to help you
determine the Tier the medication falls and the copay.
How are prescription contraceptives covered by ES?
The Cornell Program for Healthy Living covers oral contraceptives and
barrier methods (e.g., diaphragm) with a prescription at $0 copay for generics and
single source brands (in-network). If your doctor determines that the covered
generic or single source contraceptive option would be medically inappropriate,
they can prescribe a medically appropriate multisource contraceptive. It will be
covered with a $0 copay. If you go to an out of network pharmacy, you will pay
an additional $10 copay.
The Aetna PPO and Aetna H S A cover oral contraceptives and barrier methods
subject to the applicable ES copays.
Note: contraceptives that are injectable or implantable continue to be covered
under the Aetna medical plan as part of the routine office visit. For CPHL
members, it is covered at 100% and all other Aetna plans subject to the copay or
coinsurance; in-network.
Does ES cover Over-the-Counter (OTC) medications?
Only the CPHL Plan provides coverage for over-the-counter contraceptives with a
prescription. The following OTC contraceptives are covered: female condom,
sponge, and spermicide. Emergency contraceptives: Plan B and ella are covered at
$0 copay for generics and single source brand (in-network) through ES. If your
doctor determines that the covered generic or single source contraceptive option
would be medically inappropriate, they can prescribe a medically appropriate
4
ES Q&A Effective 1/1/2015
Revised 10/27/14
Page 5 of 9
multisource contraceptive. It will be covered with a $0 copay. (Out-of-network:
you pay an additional $10 copay. Tier 1: $15, Tier 2: $40, Tier 3: $60).
If I have coverage under my spouse/domestic partner’s plan, can I submit
receipts for prescriptions covered partially through their plan health plan?
No. The endowed health plans through ES does not have a coordination of
benefits provision.
How do I find out if my medications are on ES’s Formulary?
You can call ES’s Member Services at (800) 230-0508. Member Services will be
able to help you determine if your medication is on ES’s formulary list. If it is not,
then you’ll have to pay $50 for drugs purchased at a Preferred Retail Pharmacy
for up to a 30-day supply or $90 if using ES Home Delivery for a 90-day supply
of maintenance medications.
How do I access ES’s Formulary if I am not yet enrolled in an Endowed
Health Plan?
How to access the ES Formulary on the ES Website www.express-scripts.com
On the left side of the screen, click on “Clients”
Next screen, scroll to the bottom and click on “Interactive Preferred Prescriptions
Formulary Tool”
Enter medication name (minimum of four letters required), then click on “Select”
You will be provided with the drug name, available dosage, formulary status and
whether the drug is generic or brand name. Contact ES at (800) 230-0508 with
questions.
Do some medications require coverage review/prior authorization?
Yes. The pharmacy will let you know if your health plan requires additional
information. You or the pharmacy can then ask your doctor to call a special tollfree number. If using ES Home Delivery, ES will call your doctor to start the
review process. This call will initiate a review that typically takes 1 to 2 business
days. Once the review is complete, ES will notify you and your doctor of the
decision. You always have the right to appeal any decision.
This is not a complete list of medications. The drugs listed in the category are
examples. You can contact ES if you need to review the medications for each
category.
-Allergy & Asthma Therapy (such as Xolair®)
-Antineoplastic Agents (Gleevec® )
-Appetite & Weight Loss Therapy (such as Meridia®)
-Erythroid Stimulants (such as Procrit®)
-Growth hormones (such as Genotropin® and Saizen®)
-Interferon Agents (such as Peg-Intron®)
-Multiple Sclerosis Therapy (such as Rebif®)
-Myeloid Stimulants (such as Neulasta®)
5
ES Q&A Effective 1/1/2015
Revised 10/27/14
Page 6 of 9
Do some medications have a quantity limit?
Yes. Medications used to treat erectile dysfunction (e.g., Viagra).
How do I find out more about medications requiring coverage review/prior
authorization?
For more information or a detailed listing of medications, please visit
www.express-scripts.com and click on “Drug information” in the “Prescriptions
& benefits” section. If you are a first-time visitor to www.express-scripts.com,
take a moment to register. (Be sure to have your member ID number and a recent
retail or ES Home Delivery prescription number handy.) Or call ES Member
Services at (800) 230-0508.
Who approves the coverage review?
ES will contact your doctor to find out why the non-preferred medication is
needed. ES will make a determination, approval or denial of the coverage based
on information received from the doctor. If coverage is approved, you simply pay
your normal co-payment for the medication. If coverage is not approved, you will
be responsible for the full cost of the medication or, if appropriate, you can talk to
your doctor about alternatives that may be covered. (You have the right to appeal
the decision. Information about the appeal process will be included in the letter
that you receive.)
How much do I pay if the medication is approved?
If coverage is approved, you simply pay your normal co-payment for the
medication.
How much do I pay if the medication is not approved?
If the coverage is not approved, you pay the full cost of the medication.
When is a coverage review not approved?
The most common reason for a denial is that a doctor does not respond to the
coverage review request.
What happens if I don’t obtain a coverage review before filling my next
prescription/refill for the non-preferred medication?
At retail: The prescription will be stopped and you’ll be informed that a coverage
review is needed. Your options include paying 100 percent of the cost, waiting for
a coverage review, or trying an over-the-counter (OTC) product, if applicable.
At ES Home Delivery: The prescription will be stopped and an ES pharmacist
will reach out to your doctor for a coverage review. If your doctor authorizes the
switch, the new medication will be dispensed and a letter will be sent to you. If a
coverage review is approved, the medication will be dispensed as written. If a
coverage review is not approved, your options include paying 100 percent of the
cost or trying an over-the-counter (OTC) product, if applicable.
ES will not switch a medication without approval from the doctor.
6
ES Q&A Effective 1/1/2015
Revised 10/27/14
Page 7 of 9
How long does a coverage review take to complete?
The time needed to complete the coverage review depends on your doctor’s
response to ES’s request.
What if I don’t agree with the coverage review decision?
You can file an appeal with ES at 8111 Royal Ridge Parkway, Irving, TX 75063
How do I get started using ES Home Delivery for medications?
Let your doctor know that you have a Home Delivery prescription drug program
and that you would like to have the maximum supply of medication (usually 90
days) plus refills for up to one year. You may mail your prescription(s) using an
Express Scripts New Patient Home Delivery Form, refer to our web link below:
https://www.hr.cornell.edu/benefits/health/medco_delivery.pdf
Mail to Express Scripts, PO Box, 747000, Cincinnati, OH, 45274-7000 or ask
your doctor to call (888) EASYRX1 (888-327-9791) for instructions on how to
fax the prescription. If your order is faxed, your doctor must have the member
number (Employee ID number, not your social security number) from your ES ID
card.
How much will I pay for my maintenance medications through ES Home
Delivery?
You will pay $10 for generics, $60 for drugs on ES’s formulary and $90 for drugs
not on ES’s formulary for a 90-day supply instead of the maximum 30-day supply
at retail.
Note: if you are enrolled in the HSA Plan administered by Aetna, you must first
meet the applicable deductible. For medications that are considered preventive
and are listed on the “ES Always or Sometimes Preventive Drug List for the HSA
Plan” medications list, you pay the applicable copay. The deductible does not
apply. Refer to http://hr.cornell.edu/benefits/health/hsa.html to review ES’s
Preventive Drug List.
I’m used to going to my local drugstore. Why should I switch to ES Home
Delivery?
If you’re taking medication regularly, you may be able to save money by using
the Home Delivery plan, since the Home Delivery plan usually is based on 90-day
prescriptions. In addition, you’ll save time with the convenience of Home
Delivery. (Your initial prescription will be delivered within 10 to 14 days of your
call.) And refill orders can be ordered online and delivered within seven days.
How can I check on the status of my ES Home Delivery order?
You may call ES Member Services or check on their web site. You can find out
the date your prescription was received, the status of your order, the date your
prescription was mailed to you, and other billing and timing data.
7
ES Q&A Effective 1/1/2015
Revised 10/27/14
Page 8 of 9
How do I order refills from ES Home Delivery?
Order online any time, or call (800) 4REFILL (800-473-3455) and use the
automated telephone system. You can also mail in your refill orders by using the
special Home Delivery envelope. If you order by phone or via ES’s web site, at
www.express-scripts.com, you will need to provide your member number and the
12-digit prescription number found on the medication container and the refill slip.
How do I order additional ES Home Delivery envelopes or claim forms?
You can order Home Delivery envelopes or retail claim forms anytime online. Or,
you can call your Member Services toll-free number to use the automated
telephone system. The requested materials will be mailed to you right away.
If I will be traveling and need to have more than a 30-day supply from my
local retail pharmacy or more than a 90-day supply from Home Delivery,
what do I need to do?
At your local pharmacy, let the pharmacist know that you need a vacation supply.
The pharmacist will contact ES to obtain an authorization to dispense a vacation
supply.
If you require more than a 90-day supply of medication from ES Home Delivery,
have your physician write for the required day supply. You will need to contact
Benefits Administration to obtain approval before you send your prescription or
obtain a refill. The contacts in Benefits Administration are Ting Shih Okawachi at
607-255-7508 or Alison Knapp-Ward at 607-255-8487. Please be sure to provide
at least two weeks to coordinate the travel advance supply.
Please be sure to allow enough time so your request can be processed at your
local retail pharmacy or through ES Home Delivery without any delays.
What is ES’s Personalized Medicine Program?
New genetic tests have been developed to help doctors prescribe the most
appropriate drug and dosage for each patient’s condition. Your prescription drug
coverage now includes a Personalized Medicine Program that gives you the full
benefit of these advances.
If you are using a medication covered by the Personalized Medicine Program,
such as warfarin for a heart condition or tamoxifen for breast cancer, a pharmacist
will contact your doctor to see if it is appropriate for you to participate in the
program. If your doctor agrees, you will then be contacted by a pharmacist to let
you know that the testing is available. If you agree to participate, you will receive
a cheek swab test that you can administer on your own. It’s as simple as rubbing a
swab on your cheek and mailing it back in an envelope. The results will be sent to
your doctor and to a specially trained ES pharmacist who can help your doctor
interpret the results of the test. Of course, your doctor decides which drug and
dose is right for you.
8
ES Q&A Effective 1/1/2015
Revised 10/27/14
Page 9 of 9
The Personalized Medicine Program is available to you at no additional cost and
it requires no action on your part. To find out more, please call ES Member
Services.
While every attempt has been made to ensure the accuracy of this Summary, in the event of any discrepancy the Summary
Plan Description and Plan Documents will prevail.
Benefit Services 11/14
9