Page 19 - Work Force June 2025

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.
June 2025
The Work Force 19