If you are a Medicare-eligible State Health Plan member, you should have received an important mailing in October about a new Medicare Part D prescription plan. The State Health Plan will implement an Express Scripts Medicare™ Part D Prescription Drug Plan for all Medicare-eligible members, effective Jan. 1, 2013.

The most important things to know are: 

• There is NO premium for the Express Scripts Medicare Part D Prescription Drug Plan
• Out-of-Pocket costs remain capped at $2,500 annually, whether you take the new Express Script Medicare Part D Prescription Drug Plan OR you opted out and remain in the Traditional Prescription Drug Plan
• Co-pay levels remain the same (except for some specialty medications, which may be lower)
• There is no donut hole or coverage gap with the new Express Scripts Medicare Part D Drug Plan
• Diabetic supplies and immunizations remain covered
• This is not a lifetime commitment.  You are able to unenroll from the Express Scripts Medicare Part D Prescription Drug Plan at any time.

Additional benefits available only to those enrolled in the new Express Scripts Medicare Part D Prescription Drug Plan include:

• Elimination of member pay the difference on brand name drugs with a generic equivalent. (This can save you money if your physician prescribes a brand name drug rather than generic to avoid adverse interaction with other medications you currently take.)
• Premium reduction of more than $50 monthly for members paying dependent coverage for Medicare-eligible dependents
• $0 copay/31 days for over-the-counter heartburn medications (Prilosec®, Prevacid®, Zegerid®) with a prescription (Traditional Prescription Drug Plan has a $5 co-pay)
• Extra help for qualified low income members for copays and premium reduction
• Availability of specialty medications at any in-network pharmacy
• Extra medication counseling by Express Scripts pharmacists

Unless you opted out of the new Express Scripts Medicare™ Part D Prescription Drug Plan, you are automatically enrolled in the new program. Your welcome packet should arrive by mail in December, and will include important information including a new prescription drug ID card.

If you failed to receive the mailings and wish to opt out, you should immediately call the State Health Plan Customer Service at 888-234-2416. Important note: If you opt out, you will lose the additional benefits described above under the Express Scripts Medicare™ Prescription Drug Plan.

The following are major considerations in making your final decision:

• State Health Plan members can NOT be enrolled in the Express Scripts Medicare Part D Plan if they are enrolled in a Medicare Advantage Plan. If you wish to remain in a Medicare Advantage Plan, you MUST opt out of the Express Scripts Medicare Part D Drug Plan: The Center for Medicare and Medicaid Services (CMS) does not permit members to be enrolled in two Medicare Part D plans at a time. Members will be disenrolled from any individual Medicare Part D plan and Medicare Advantage Plan in which they are already enrolled.
• Most plan members will save money by remaining in the Express Scripts Medicare Part D Drug Plan, but the only way to know for sure is to call Express Scripts Customer Service at 877-680-4882.

A very small percentage (2-5%), might pay a slight amount more since there is a slight variation in the formulary between the Express Scripts Medicare Part D Prescription Drug Plan and the Traditional Prescription Drug Plan.
Prior to calling, make a list of all prescription medications you take, the dosage level and frequency. Then when you call, ask the following questions of the Express Scripts Customer Service:

1. Are any of the prescriptions I currently take considered non-preferred brand name drugs or specialty medications in the Express Scripts formulary? If the response is yes, then ask for the co-pay amount and compare that to the co-pays you currently make for those prescriptions. Also ask for Express Scripts Preferred Brand Name Drugs to replace any non-preferred brand name drugs you may be taking, and consult with your personal physician on switching to a preferred brand name prescription.
2. Do any of the prescriptions I currently take require prior approval? If the response is yes, make a request that Express Scripts go ahead and begin the prior authorization process for those medications requiring prior approval beginning January 1.

NOTE 1: Prior authorizations for medications currently on file in the Traditional Prescription Drug Plan will not carry over to the new Express Scripts Medicare Part D Prescription Drug Plan.  Therefore, members will need to take action and obtain a new prior authorization within 60 days of their effective date in this plan (1/1/13). You will be able to receive a one-time transition supply (31 days) in January 2013.

NOTE 2: Veterans eligible for Tricare for Life may wish to opt out and remain in the Traditional Prescription Drug Plan since Tricare pays whatever the State Health Plan doesn’t cover. 

Members and providers will need to call the following Express Scripts phone number in January to initiate a new review: 800-935-6103.  Medications requiring prior authorizations are different than the Traditional Drug Plan and members should refer to the Plan website for more details at www.shpnc.org.

CALENDAR YEAR CONVERSION: The new plan switches a member's pharmacy benefit to a calendar year, which means your out-of-pocket maximums do not change, but will start over Jan. 1, 2013. The pharmacy out-of-pocket maximum of $2,500 will be cut in half to $1,250 for the period July 1, 2012- Dec. 31, 2012. Refunds for the total amount over $1,250 will be issued the first quarter of 2013.

Questions? Information is available on the State Health Plan website at www.shpnc.org. Express Scripts Customer Service is also standing by to your answer questions. You may call Customer Service at 877-680-4882, 24 hours a day, 7 days a week. TTY users should call 800-716-3231.