ESI Formulary – MCSIG is adopting Express Scripts’ (ESI) broader, more extensive formulary. Under the ESI Formulary, there will be more drugs available to you at the Formulary Brand copays. The ESI formulary is created based on physician and pharmacist evaluation of clinical data. There are formulary alternative drugs to almost all non-formulary medications. If you are currently taking a medication that is not on ESI’s formulary (a non-formulary medication), you will receive separate information from Express Scripts as to your options. You can find out if a drug is on the ESI formulary by going to www.express-scripts.com, logging in, then clicking on ‘coverage & copayments’.
30 Day Retail – Effective July 1, 2008 MCSIG’s retail copayment amount will be for a 30 day drug supply. You can still obtain a 60 day drug supply at retail for two 30-day copayments. If your medication is a maintenance medication you will need to convert that prescription to the Express Scripts Home Delivery Program by September 2008. See the Exclusive Home Delivery discussion below.
Drug Quantity Management (DQM) - This new program only applies to a limited list of drugs. A current list of drugs subject to the DQM program limits can be found at www.mcsig.com. The DQM program assures that the quantity of drug supplied for each copayment is consistent with clinical dosing guidelines and your copayment benefit. If your prescription is for a larger quantity than the DQM quantity limit you have three options:
- You may choose to receive the prescribed amount at additional out-of-pocket cost (in addition to your applicable copay amount you would pay the difference between the cost of the quantity dispensed and the cost of the quantity limit); or
- You can ask your doctor to prescribe a different amount or dose consistent with the DQM limits; or
- You can ask your doctor to request an override of the DQM quantity limit by calling Express Scripts at 1-800-417-8164 or by faxing the request to 1-800-357-9577. These numbers are for the doctor’s office ONLY. All requests must come from the doctor and they must have the following information: Patients first and last name, Birth date of patient and the medication name.
You can find out if a drug has a DQM limit by going to www.express-scripts.com, logging in, then clicking on ‘coverage & copayments’.
Exclusive Home Delivery (Prescriptions by Mail) – As of 7/1/2008 your pharmacy benefit will cover up to two retail fills of each of your maintenance medications at a participating retail pharmacy. Afterwards, you will need to order these prescriptions through Home Delivery from Express Scripts. If you are currently filling a maintenance medication at retail you will receive separate information from Express Scripts as to your options.
- What is a Maintenance Medication? A maintenance medication is a prescription drug that treats an ongoing condition such as diabetes or high blood pressure.
- Can I still fill my maintenance medication prescriptions at my retail pharmacy? Your benefit plan after July 1, 2008 will cover up to two retail fills of each of your maintenance medications at a participating retail pharmacy. Afterwards, you will need to order these prescriptions through Home Delivery from Express Scripts.
- How do I get started with Home Delivery?
- Have your doctor write two prescriptions:
- One written for a 30 day supply at retail to give you time to get set up for Home Delivery
- One written for a 90 day supply with 3 refills to send in for home delivery.
- Mail your prescriptions to Express Scripts with the attached Home Delivery Form OR have your doctor fax the form and prescriptions to Express Scripts at: 1-800-396-2171.
- Important reminder – prescriptions that do not contain the following information could be delayed or returned:
- Be sure your doctor includes his or her name, phone number, DEA number and signature on the prescription(s).
- The prescription(s) should also include your name, date of birth, mailing address and member ID.
- Your mail-order prescription may not be mailed right away due to your obtaining a 30 day prescription at retail. Generally, the mail order prescription will be mailed when a two weeks’ supply remains on your retail fill.
- Are there other ways to register for Express Scripts Home Delivery? Yes.
- If you’re new to Home Delivery, you can complete the order form or set up an account online at www.starthomedelivery.com
- If you currently use a retail pharmacy for your maintenance prescriptions you can contact an Express Scripts Patient Care Advocate that can assist you with getting set up for Home Delivery by calling the number on the back of your ID card. New prescriptions set up this way can take 2 – 3 weeks to process.
- How can I order refills of my Maintenance Medications being filled by Express Scripts Home delivery?
- Log on to www.starthomedelivery.com and click on “order refills”.
- Call the customer service number on the back of your ID card, 24 hours a day, seven days a week.
- What happens if I lose, destroy or otherwise need an emergency supply of a drug or EpiPen I get through Express Scripts Home Delivery?
- You are eligible for regular refills of your Express Scripts Home Delivery prescriptions thirty-four (34) days prior to your current supply running out. See the above bullet point for how to order refills of Express Scripts Home Delivery prescriptions.
- You can call Express Scripts at 1-866-321-9650 or MCSIG customer service at 831-755-8055 or 800-287-1442 and request an emergency override.
- You can call your doctor and request he/she provide you with an emergency 30 day prescription. You will be able to fill this new emergency prescription up to two times at retail.
- What if my maintenance medication is temperature sensitive?
- Express Scripts ships temperature sensitive drugs via overnight in insulated containers with frozen gel blocks and packaged specifically for the intended transit path across the country. A label on the package includes storage warnings. You can have these medications shipped directly to your home, or if you prefer, to your place of employment, a neighbor, etc.
- What if my prescribed insulin or other diabetic medication dosage does not correspond with standard pharmacy packaging?
- If your prescribed quantity or dosage does not correspond with any drug manufacturer’s standard packaging, Express Scripts Home Delivery will dispense upward to a full packaged amount (you will not be shipped a quantity or dosage less than what you have been prescribed).
- What about the specific co-pays MCSIG has currently set up for insulin, swabs, test strips, lancets and calibration solutions?
- These items are dispensed at the generic co-pay rate in effect at the time they are filled. Since these are typically maintenance items you will need to convert these items over to Express Scripts Home Delivery by September 2008.
- What if insulin or other diabetic therapy is my maintenance drug?
- If you are currently receiving insulin or other diabetic therapy Express Scripts will be sending you additional information concerning receiving diabetic related therapies through the Express Scripts Home Delivery feature.
- How will Express Scripts know about my allergies and medication interactions?
- When you register for mail order prescription you will have an opportunity to provide Express Scripts with information concerning your allergies and other medications you are taking. The mail order pharmacists will have access to this information and if they see a potential issue with a medication you have been prescribed, the pharmacist will contact your physician directly.
- What if I need to speak directly with a pharmacist about my medications?
- Express Scripts Mail Order Pharmacists are available to speak with you 24/7. Call Express Scripts at 1-866-321-9650 and tell the Customer Service Representative that you need to speak directly with a pharmacist concerning a medication question.
- What happens when I send in one form for multiple prescriptions?
- Express Scripts strives to keep prescription orders together when possible; however, there are situations in which splitting an order is required to prevent unnecessary delays of other medications included in the order. When a multiple prescription order has been delayed for seven (7) calendar days or more due to an intervention, you should receive an outbound patient call from Express Scripts.
CuraScript – As a reminder, all specialty medications must go through CuraScript Pharmacy after one fill at retail. Specialty medications treat chronic, complex conditions such as hepatitis C, multiple sclerosis and rheumatoid arthritis. Although the incidences of these and other serious diseases are being diagnosed more commonly, the medicines needed to treat such conditions are far from common.
Express Scripts defines specialty medications as injectable and noninjectable drugs having one or more of several key characteristics, including:
- Requirement for frequent dosing adjustments and intensive clinical monitoring to decrease the potential for drug toxicity, and increase the probability for beneficial treatment outcomes
- Need for intensive patient training and compliance assistance to facilitate therapeutic goals
- Limited or exclusive product availability, and distribution
- Specialized product handling and / or administrative requirements
- Cost in excess of $500 for a 30-day supply
Please call 1-866-848-9870 if you are on a specialty injectable medication or specialty drug.
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