Page 17 - Work Force June 2022

Empire Plan prescription drug savings options
The cost of prescription drugs is one of the fastest growing components of health care costs in the United States.
The Empire Plan’s prescription drug benefit is designed to help manage drug costs and establish copayment levels that are more in line with the relative cost of various drugs to the Plan.
Each January, Empire Plan enrollees are sent the Empire Plan at a Glance, which is a summary
of benefits available under
the Empire Plan, and
also includes applicable copayment(s).
Copayments are not
the only component
that impacts overall
health insurance costs.
To keep out-of-pocket
costs for prescription
drugs as low as possible,
speak with your doctor about alternative drugs that may be available for your treatment and become aware of programs that can help you save money.
The Empire Plan Prescription Drug Program uses the Advanced Flexible Formulary to provide CSEA enrollees and dependents with the best value in prescription drug spending. All drugs included on the formularies
have been approved by the FDA. The list is developed by a committee of pharmacists and physicians and are subject to change each January.
The Empire Plan Advanced
Flexible Formulary uses a three-level copayment schedule – Level 1 has the lowest copayment and most generic prescription drugs fall within this level.
Empire Plan Mail Service Pharmacy
The most cost-effective way to receive your prescription drugs
is through the Mail Service Pharmacy. When you fill
your covered prescription drugs through the CVS Caremark Mail Service
Pharmacy, you can order up to a 90-day supply shipped to your home.
An order form can be printed at www.cs.ny.gov/
employee-benefits. From the NYSHIP homepage, select
Forms and scroll down to choose CVS Caremark Mail Service Order Form. You can call the Empire Plan toll free at 1-877-7NYSHIP (1-877-769-7447). Press or say 4 for the Prescription Drug Program.
Specialty Pharmacy Program
The Empire Plan Specialty Pharmacy Program offers enhanced
services to individuals using specialty drugs. Most specialty drugs will only be covered when dispensed by The Empire Plan’s designated specialty pharmacy, CVS Caremark Specialty Pharmacy. Prior authorization is required for some specialty drugs.
A complete list of specialty drugs included in the Specialty Pharmacy Program is available on the New York State Department of Civil Service website at https://www.cs.ny.gov. Select Benefit Programs, then NYSHIP Online and follow the prompts to the NYSHIP Online homepage. Click on Using Your Benefits and then select Specialty Pharmacy Drug List. Each of these drugs can be ordered through the Specialty Pharmacy Program using the CVS Caremark Mail Service Order Form.
Additional cost-saving ideas
• Talk with your doctor about using over-the-counter drugs. Prescription drugs occasionally move to the over-the-counter market and are then available without prescriptions. An over- the-counter drug may be a cost- effective alternative to your prescription medication.
• When your doctor starts you on a new maintenance prescription drug, you may want to have
the prescription filled for a 30-day supply to ensure the prescription is right for your condition before paying a higher copayment for a 31 to 90-day supply.
• Ask your agency health
benefits administrator or business services center if you are eligible to participate in New York State’s Health Care Spending Account, which allows you to set aside part of your salary before taxes to pay for health-related expenses or visit www.flexspend.ny.gov for more information.
• Don’t use the Empire Plan Prescription Drug Program for drugs related to a workers’ compensation injury. These claims should be covered in full by workers’ compensation.
For more information
Additional online resources are available on the Empire Plan’s
CVS Caremark website. Visit www.empireplanrxprogram.com and select the CVS Caremark link or call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and press 4 for the Prescription Drug Program.
Understanding Empire Plan benefits: preventive, diagnostic and routine care
Preventive, diagnostic and routine care benefits are common types of health care you may receive under The Empire Plan.
Understanding the difference between them is not always easy, but it is important. Coverage and out-of- pocket expenses can vary depending on which type of service you receive. Be sure to discuss with your provider why a test or service is being ordered. The same test or service can be considered preventive, diagnostic, or routine (depending on the description of why it is being performed). As a result, out-of-pocket costs paid by the enrollee may change based on why the service is requested.
Preventive care benefits and services covered by The Empire
Plan follow numerous guidelines and standards, including recommendations
by the U.S. Preventive Services Task Force (USPSTF), the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services and the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) as
well as requirements of the Patient Protection and Affordable Care Act (PPACA).
The goal of preventive care is to detect potentially serious health conditions before symptoms develop and obtain early treatment. Preventive care can include annual exams, screenings, and immunizations.
Common examples of adult preventive care include annual wellness visits, cholesterol, high blood pressure and diabetes screenings as well as cancer screenings, such as
colonoscopies and mammograms. Common examples of yearly pediatric preventive care (well-child) can include growth and body mass measurements, developmental screenings, behavioral assessments, and immunizations. Many preventive services are covered in full when using an Empire Plan participating provider.
Diagnostic care helps diagnose risk factors or treat symptoms that are already present. Diagnostic care would involve following up with your provider to treat or monitor issues. When a preventive visit becomes diagnostic, a copayment would apply when using a participating provider.
Routine care describes care that occurs on a regular basis, but it
is not preventive. Routine care is used to prevent a condition from becoming worse and to help manage
symptoms. Common illnesses that often require routine care include asthma, hypertension, and diabetes. Because routine care is not preventive, a copayment would apply when using a participating provider.
Please review the 2022 Empire Plan Preventive Care Coverage Guide for more details regarding preventive, diagnostic and routine care. You should review your Explanation of Benefits Statement (EOB) regularly. The EOB can provide a better understanding of how the services are billed, what the Plan pays and your out-of-pocket costs.
If you have specific coverage questions or need assistance finding a participating provider, call the Empire Plan 1-877-7-NYSHIP (1-877-769-7447).
June 2022 The Work Force 17