Page 16 - Work Force June 2024

Prescription drugs are one of the
fastest-growing components of
health care costs in the United States
and The Empire Plan.
The Empire Plan’s prescription
drug benefit is designed to help
manage drug costs and establish
copayment levels that are closer
to the relative cost of most drugs.
While prescription drug copayments
have increased in the past, the plan
continues to pay most of the cost of
covered prescriptions.
Empire Plan
copayment levels
Each January,
Empire Plan
enrollees are sent
the Empire Plan at
a Glance, which
is a summary of
benefits available
under The Empire
Plan, which also
includes applicable
prescription drug
copayment(s). To
help keep enrollee
out-of-pocket prescription
drug costs as low as possible, it is
helpful to discuss your prescription
drug program requirements and out-
of-pocket responsibilities with your
health care provider as there may
be alternative prescriptions that are
medically appropriate for you, but
available at lower enrollee out-of-
pocket costs.
The Empire Plan Prescription
Drug Program has three levels of
copayments. Prescription drugs
available under the Empire Plan’s
Level 1 copayment tier have the
lowest copayment and include most
generic drugs and certain brand-
name drugs. Level 2 copayment
tier have a mid-range copayment
and include preferred or compound
June 2024 17
The Work Force
must first evaluate whether
covered drugs on the formulary are
suitable alternatives. The physician
may submit a letter of medical
necessity and any supportive
clinical documentation showing
an appropriate trial of formulary
alternatives to CVS Caremark.
Empire Plan mail service pharmacy
One of the most cost-effective
ways to receive prescription drugs is
through the mail service pharmacy.
Covered prescriptions filled
through the CVS Caremark Mail
Service Pharmacy can be up to a
90-day supply shipped to your home.
If taking prescription medications on
a long-term basis, the mail service
pharmacy may save time and money.
Specialty Pharmacy Program
The Empire Plan Specialty
Pharmacy Program offers enhanced
services to individuals using
specialty drugs. Most specialty
drugs will only be dispensed by the
Empire Plan’s designated specialty
pharmacy.
Specialty drugs are used to treat
complex conditions and usually
require special handling, special
administration or intensive patient
monitoring.
The complete list of specialty
drugs included in the Specialty
Pharmacy Program is available on
NYSHIP Online at www.cs.ny.gov/
employee-benefits, click on using
your benefits and select Specialty
Pharmacy Drug List.
Cost-saving Ideas
•
Discuss the possible use of
over-the-counter drugs with
your physician. There may be
a cost-effective alternative.
•
When starting a new
maintenance prescription
drug, filling for a 30-day
supply will help ensure the
prescription medication
is right for you and your
condition before paying for up
to a 90-day supply.
•
Research enrolling (for the
next calendar year) in the
Health Care Spending Account,
which allows you to set aside
part of your salary before
taxes to pay for health-related
expenses or visit oer.ny.gov/
health-care-spending-account.
•
Should you have a Workers’
Compensation injury, do
not use The Empire Plan
Prescription Drug Program.
These claims should be
covered in full by Workers’
Compensation.
You can get more information
about the Empire Plan Prescription
Drug Program by calling
1-877-7-NYSHIP (1-877-769-7447) and
press or say 4 for the Prescription
Drug Program.
Empire Plan
prescription drug
information
drugs that have been selected
because of their overall health
care value. Level 3 copayment tier
drugs have the highest copayment
and include non-preferred drugs,
which, in many cases have a generic
equivalent and/or one or more
preferred alternatives.
Mandatory generic substitution
If the prescription is written for a
covered brand-name drug that has a
generic equivalent, New York State
law requires generic substitution
unless the brand-name
drug has been placed
on Level 1.
If the physician
believes it is
medically
necessary to take
a covered brand-
name drug that
has a generic
equivalent,
an additional
ancillary cost
(difference in cost
between brand and
generic) will apply.
To appeal the ancillary cost,
the physician can submit a letter of
medical necessity to CVS Caremark
for a medical exception. If the
medical exception is approved, the
Dispense as Written (DAW) will be
indicated on the prescription and
only the Level 3 copayment will
apply (no ancillary charge).
Exclusions
In some cases, drugs may
be excluded from coverage if a
therapeutic equivalent or over-the-
counter drug is available. Enrollees
may file a medical exception appeal
to receive coverage for drugs
excluded from their formulary.
Enrollees and their physicians