Page 18 - Work Force June 2025

June 2025 19 19
The Work Force
Learn more about
the Empire Plan’s
prescription drug benefit
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. There may
be alternative prescriptions that are
medically appropriate for you, but
available at a lower enrollee out-of-
pocket cost.
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
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
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 savings
•
Discuss the possible use of
over-the-counter drugs with
your physician, which 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 setting aside
part of your salary before
taxes to pay for health-related
expenses or go to
https://oer.ny.gov/fsa.
•
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.
Additional information about
the Empire Plan Prescription Drug
Program can be obtained by calling
1-877-7-NYSHIP (1-877-769-7447) and
press or say 4 for the Prescription
Drug Program.