Why is my prescription non-preferred? The State is working to promote cost-effective use of prescription drugs where medically appropriate. To a large extent the program does this through the use of a formulary which is a complete list of drugs that the State's drug plan covers which include four tiers of co-payments. Often name-brand medications are non-preferred and are subject to higher co-pays when there are effective, lower-cost drugs that can treat the same condition.
When do prescription formularies change? Formularies will change when a new pharmacy benefit manager (PBM) is chosen. However, formularies change over time even without changing PBMs and the State's health plan formulary may even change mid-year. Formulary changes can be advantageous for members if they introduce new medications or promote cost savings. However, changes can also adversely affect members by increasing drug costs on certain name brand medication.
How can I lower my drug co-pay? There are effective, lower-cost drugs that treat the same health conditions as non-preferred medications. You can search for options on the MedImpact website https://medimpact.com/mp/public/Login.jsp?viewtype=mi using the Drug Price Check feature. Enter in your current drugs name and press the search button. Select the dosage level that is appropriate and your current drug will be listed. Below you will see a box that says "View Most commonly Dispensed Similar Drugs" and click on that. This will bring up alternative medications that belong to the same specific drug class as your current medication. This provides you with a list of alternative drugs that can reduce your co-pay amounts that you can discuss with your doctor.
What are specialty medications? Specialty medications help patients with complex conditions like multiple sclerosis, cancer, rheumatoid arthritis or hemophilia. Some specialty medications are available only through limited distribution and they are expensive. As a generic definition specialty drugs are generally considered high-cost injectables, infused, oral or inhaled drugs that require supervision and monitoring.
Who creates the drug formulary? The State utilized our Pharmacy Benefit Manager's standard formulary which is developed through their Pharmacy & Therapeutics (P&T) Committee. This group also determines which medications are classified as specialty medications. Formulary drugs are reviewed quarterly by MedImpact for safety, efficacy, indications, ease of use, potential for adverse effects, and cost effectiveness. The P&T Committee consists of physicians, pharmacists, and clinicians representing a broad range of clinical practice and expertise.
Why are specialty medications limited to a 30 day supply? The goal is to limit the potential waste of prescription drugs and money spent on member copayments and State's payments. It is extremely expensive when specialty drugs are discarded if it is determined that the member is not responding the the medication, cannot tolerate the drug, develops an allergic reaction, has an unacceptable side effect, or passes away. These medications are expensive. Humira for example, is a specialty injectable drug which costs approximately $1,375 in 2012 for a 28 day supply or $16,500 over the course of a year. The 30 day limitation is primarily aimed at the high cost of wasted specialty drugs which occurs when a patients treatment plan changes where a specialty medication is changed or the dosage revised during the course of treatment. The Wyoming State Employees' and Officials' Group Plan does have the 30 day fill limitation which we adhere to.
Why does the State require that specialty medications be filled by Diplomat Specialty Pharmacy? Specialty drugs are the fastest-growing segment of pharmaceutical spending within the State of Wyoming pharmacy benefit creating financial pressure to develop better methods to track and manage the use of these products. Product discount contract rates for drugs vary by distribution channel and are typically most aggressive within the specialty pharmacy distribution channel. Several years ago the State chose to move to utilizing specialty pharmacies in this category to minimize the cost to the State to help keep premiums in check. As an example, and 8% differential on a specialty product with an average wholesale price of $1,800 represents $144 per claim which over times creates significant savings over the course of a year.
What is step therapy? Step therapy is a type of prior authorization for prescription medications. For many ongoing medical conditions, there are a number of medication choices that are proven to be safe and effective. When a medical condition can be treated successfully by the therapeutically equivalent medications, it makes sense to choose the medications that offer appropriate care at the lowest out-of-pocket cost. With step therapy, in most cases, individuals must first try certain less expensive drugs in the same treatment class that have been proven effective for most people with certain conditions before they can move up a "step" to a more expensive drugs. Often, the most cost-effective therapeutic option is a generic medication. Generic medications have been certified by the Food and Drug Administration to be just as safe and effective as their brand name counterparts.
If an individual has already tried the similar, less expensive drug and they did not work, or if their prescribing physician believes the patient's medical condition makes it medically necessary for them to be on the more expensive step therapy prescription drug, the prescribing physician can file a "Medication Request Form" to ask for an exception. Physicians can request the Medication Request Form by contacting MedImpact. If a prescribing physician's request is approved, the state will cover the step-therapy prescription drug.
How do I add a new dependent? To add a new dependent to your health and dental plan you must complete an application for the new Dependent and send it to your benefit specialist within 60 days of the date you acquired the dependent(s). If you do not have the appropriate documentation (birth certificate, marriage certificate, etc.) do not wait to submit your applications; as they are date sensitive. Employees' Group Insurance will contact will contact you if the appropriate documentation is missing. Supporting documentation must be received before coverage will be made effective. Applications received after the 60 days will be denied and the next opportunity to enroll your dependents will be the upcoming open enrollment period.
What if I have a baby? Newborn children will be covered for up to 31 days after their birth. You must apply for Dependent coverage for the newborn child within 60 days of the date of birth and pay any required premium contributions to continue coverage uninterrupted. If the birth certificate is not available within the 60 days, do not wait to submit your applications. Do not wait for a birth certificate to submit your applications. Employees' Group Insurance will contact you after receipt of the application if not included. All applications to continue coverage for newborn children must be received within 60 days regardless of whether an employee has single or family coverage. If you have other Dependents who were previously not covered and you wish to cover them, they may be added effective the first of the month following receipt of application. Application for other dependents must be received within 60 days of the birth.
Why is there SPLIT coverage? Split coverage was created for when there is family coverage with children and both parents work for an entity covered by EGI. The reason for this is so the state contribution is split equally between both agencies/entities. One agency should not be required to pay an ENTIRE family contribution when one parent works for another agency covered by EGI. This keeps it equitable.
Why do I have to have preventive dental if I have health insurance? Preventive dental is required when enrolled in health because it is part of preventive overall physical wellness.
How long can my children stay covered? Dependent children can remain covered through the end of the month of their 26th birthday. Then they are offered COBRA coverage.
What are the qualifications to continue coverage as a retiree? Any employee who works for an entity covered by EGI who is at least 50 years of age with 4 consecutive years of service OR simply has 20 years of service AND their coverage has been in effect for a full 12 months prior to termination/retirement, qualifies as a retiree through EGI.
Why does the State require supporting documentation for dependent eligibility? The Employees' and Officials' Group Insurance program like other employers continues to struggle with controlling our benefit plans' costs. It is important to make sure that the individuals we have covered in our plans are actually eligible for coverage. With health care costs being so expensive, it's tempting for employees/retirees to cover non-eligible friends and relatives or ex-spouses on the State's health plan. By requiring supporting documentation for dependents Employees' Group Insurance (EGI) can ensure that covered dependents do in fact meet the eligiblity guidelines of the State's benefit plans. This in turn reduces healthcare costs by eliminating cliams paid for ineligible dependents and makes sure agencies/entities are not paying employer contributions for ineligible dependents. All information provided to EGI is protected health information and is kept completely confidential.
What if I am out of town and have an illness or emergency? If you are in Wyoming and the provider is out of network, then your claims would be payable at 80%; but you may owe additional amounts above the maximum allowable cost (MAC). If you are out of state and your provider is out of network, your claims would be payable at 60%.
Why haven't I received my new ID card for Explanation of Benefits? The number one reason why individuals are not receiving ID cards or explanation of benefits from the Plan is that there has been an address change and EGI has not been notified to the change of address. ID cards and explanation of benefits contain protected health information and as such will not be forwarded to the new address by the post office. These are returned to the sender which can significantly delay or prevent you from receiving this information by mail. Please check with our office to make sure we have an up to date address on file and remember to notify us if you move.
DENTAL BENEFIT QUESTIONS
Does the State's optional dental plan cover Composite (resin) fillings? Composite Restorations on anterior (front) teeth are a covered benefit, for several reasons; 1) Front teeth do not go through the stresses that posterior (back) teeth endure. 2) Front teeth are visible when we open our mouths to talk or communicate. (Usually back teeth are not as visible. 3) Composite materials adhere to front teeth better than back teeth.
Composite Restorations on posterior (back) teeth are not a covered benefit, for several reasons; 1) back teeth endure considerable stress in the chewing process of eating foods. They are used to grind up and begin digestion. 2) Restorations in back teeth are usually larger and composite materials do not adhere as readily to the tooth surface and are not as durable as amalgam. The State's optional dental program does make payments for composite fillings on posterior teeth but limits the payments to the allowable amount for amalgam.
Some people have had concerns over the safety of amalgam restoration; however, the FDA issued a final regulation regarding the use of Dental Amalgam material as being safe and an effective restorative option for patients.