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Montana University System URx: Rethinking our Rx program: A New Strategic Approach.

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Presentation on theme: "Montana University System URx: Rethinking our Rx program: A New Strategic Approach."— Presentation transcript:

1 Montana University System URx: Rethinking our Rx program: A New Strategic Approach

2 2 WHY URx  Prescription drugs are the largest and fastest rising cost component of “our plan”.  Our Plan = our self insured offerings – Medical, Pharmacy, and Dental.  We pay 100% of our pharmacy costs through our premiums and out-of- pocket cost sharing.  Prescription drugs account for roughly 31% of our health care expenditure.  We spend approximately $69,500 per day for prescription drugs.  We spend more for prescription drugs than doctors or hospitalizations.

3 3  URx  URx is a Pharmacy Benefit program “owned” by Montana University System  The “U” originally stood for University Rx URx  State Of Montana quickly partnered with MUS on the build of URx  URx  URx went live 1/1/2010 for State Of Montana  URx  URx goes live 7/1/2010 for MUS URx  Some major players helped in the design/development of URx.  Pharmacy Benefit Administrator (MedImpact)  Skaggs School of Pharmacy (University of Montana)  University of Massachusetts Medical School (MedMetrics)

4 4  Clinical Monographs From MedMetrics  PTAC (Pharmacy & Therapeutics Advisory Committee) Independent Committee consisting of the following : Chair - Mark Eichler, RP 3 Montana based Physicians 3 Montana based Pharmacists 3 Consumers - Plan Members / Union Reps  Drug is tiered A,B,C,D, or F  Efficacy evaluated first The Higher the Value,  Cost evaluated second The Higher the Drug is tiered.  Efficacy + Cost = Drug Value

5 5 URx Benefit Design URx Drug Classification (Based on medical evidence of impact to health and overall net cost) Drug Class Deductible Retail Rx (30-day supply) Mail Rx (90-day supply) Excellent level of value based on best medical evidence, best opportunity for improved health outcomes, and best overall net cost. Tier A $0$0 Copayment High level of value based on medical evidence of outcomes and lower overall net cost. Includes generic and brand drugs compared to higher cost brand name counterparts. Tier B $0$15 Copayment$30 Copayment Good level of value based on fair medical evidence grading, but displaying higher overall net cost relative to generic or brand name drug counterparts. Tier C $0$40 Copayment$80 Copayment Lower level of value based on evidence of outcomes relative to other clinical alternatives. Generally have much higher overall net costs. Tier D $0 50% Coinsurance (You will pay half of the discounted price) 50% Coinsurance (You will pay half of the discounted price) These drugs have the lowest level of value (based on clinical evidence) or the highest overall net cost in relation to generic or other brand alternatives. Class F includes drugs that were not previously covered, allowing members to purchase them at a substantial discount, if they choose. Tier F $0 100% Coinsurance (You will pay 100% of the discounted price) 100% Coinsurance (You will pay 100% of the discounted price) A copayment is a flat dollar amount you pay for Rx services. Coinsurance is a percentage of the total discounted cost you pay for Rx services.

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7 7 How Will URx Work For Me??? THE URx 4 STEP  STEP 1  Review Your Medications – Know what they are………..  Complete Name  Dosage – i.e. 10mg, 20mg. etc  Frequency – i.e. Once daily, Twice daily, etc.  STEP 2  Find out what tier your drugs received under the URx drug list.

8 8 How Will URx Work For Me??? THE URx 4 STEP  STEP 3  If they are D or F, you can find out about potential alternatives in classes A through C to discuss with your doctor. Call Ask-a- Pharmacist at 1-888-5-ASK-URX (527-5879) for assistance if needed.  We will be mailing letters to members who have D and F drugs beginning in April and again throughout the year to assist you with learning about your drugs and potential alternative drugs.  STEP 4  If there are documented medical reasons why you cannot take one of the alternative drugs with a higher grade, MUS Benefits staff can work with you to see if you are eligible to receive a better benefit for a lower grade drug. Have your PROVIDER complete and submit a Plan Exception Request form (available on-line, campus HR, or call MUS Benefits).

9 How do I find out my drug tier?  There are several ways to look up the tier of your drugs and potential alternatives: URx Call general information at URx 1-877-501-1064 On the internet go to 9

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11 11  If you are established on certain types of drugs, you can remain on those drugs with an enhanced benefit. Examples include specialty drugs, transplant drugs, and certain neurological drugs such as anti-depressants (Grandfathering).

12 12  Where do I go to fill my prescriptions ???  You can still use all of the same retail pharmacies and Ridgeway mail-order pharmacy. A new mail-order pharmacy called URx MedVantx will also be available for you to use. (MedVantx is located in South Dakota.)  Diplomat Specialty Pharmacy is the URx provider for Specialty Drug Services. If you are currently in the specialty drug program, Diplomat will be in contact with you prior to July 1, 2010. We will maintain our current $0 Protocall program through Diplomat.

13 13 With URx we can;  Reduce pharmaceutical costs to both members and the plan. We expect costs to be reduced by 20% for the plan and save members on average 20% of their overall out-of-pocket costs.  If you do your part (Steps 1 – 4)…..

14 Questions? 9

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