Express Scripts/Medco Prescription Plan Information For Drug Coverage Review, Prior
Authorization Process and Personalized Medicine Information
The endowed health plan offers faculty and staff members and their families a very
comprehensive prescription drug program at relatively low costs to the consumer. Prescription
drugs have become an important part of health plan coverage. The prescribing physicians in our
region that serve most of our participants have been relatively comparable with national
prescribing practices. But, this service category can be very expensive to plan participants and to
the plan overall. So, in the interests of patient safety, eliminating waste in the system of delivery
and yet maintaining physician-guided care, Cornell implemented coverage management
programs back in November 1, 2009. These complement a few management programs already
in place that have shown to effectively control costs.
The endowed health plan also includes a service, which will help physicians and patients access
a new category of so-called ‘specialty drugs’ at the lowest possible cost and with enhanced
support for the special delivery and use requirements of this class of drugs. Most specialty
medications can only be accessed through Accredo, a subsidiary of Express Scripts/Medco.
Cornell supports a pre-testing program that will help doctors and patients determine in advance
how a patient will metabolize a specific drug for advanced treatment. This program called
Personalized Medicine will be paid for by the health plan upon recommendation from your
Coverage reviews/prior authorization:
Some medications are not covered unless you receive approval through a coverage review. This
review uses plan rules based on FDA-approved prescribing and safety information, clinical
guidelines, and uses that are considered reasonable, safe, and effective. Likewise, there are other
medications that may
be covered, but with limits (for example, only for a certain amount or for
certain uses) unless you receive approval through a review.
During this review, ES/Medco asks your doctor for more information before the prescription can
be covered under your plan. Cornell has sent out advance notice of this program to most of the
prescribing physicians in the region.
The following drug categories listed are subject to the coverage review program and will require
pre-approval. Those drugs with an asterisk (*) have previously been subject to a coverage
review. Please note that the medications and drug categories listed are subject to change. Note
: This is not a complete list of affected medications. The drugs listed in each category are
only examples. You can contact ES/Medco (800) 417-1764, 8am to 9pm EST, Monday through
Friday) if you need to review the medications for each category.
Allergy & Asthma Therapy (such as Xolai
r®) *Antineoplastic Agents (Gleevec
® ) *Appetite & Weight Loss Therapy (such as Meridia
Erythroid Stimulants (such as Procrit
Growth hormones (such as Genotropin
® and Saizen
Interferon Agents (such as Peg-Intron
Multiple Sclerosis Therapy (such as Rebif
Myeloid Stimulants (such as Neulasta
*Smoking Deterrents (such as Chantix
*Erectile Dysfunction Agents (such as Viagra
® quantity limits)
Coverage Review/Step Therapy
Your plan uses a coverage tool called step therapy,
which requires you to try first one or more
specified medications to treat a particular condition before the plan will cover another (usually
more expensive) drug that your doctor may have prescribed. Step therapy is intended to reduce
costs for you and your plan by encouraging the use of medications that are less expensive but
still treat your condition effectively. This applies only to individuals taking Proton Pump
Inhibitors due to certain stomach conditions. The target medications and the preferred
alternatives are listed in the box below.
If you’re taking a medication that requires step therapy, you’ll receive a letter explaining that
your plan will not cover it unless you try the alternative medication first. The letter will also have
information on starting a coverage review if your doctor believes that you should take the
To avoid potential service disruption, it is important that you discuss the options with your doctor prior to your next medication fill. This will allow time for obtaining a new prescription or completing the coverage review process.
If you’re taking one of these
Ask your doctor about these lower-cost alternatives:
®, Kapidex, Prevacid
® 40 mg, Protonix
®, and pantoprazole
The coverage review process
To save you time and help avoid any confusion, we’d like to highlight the coverage review
process, both at a retail pharmacy and when using mail order. At a retail pharmacy in your plan:
You drop off the prescription with your local pharmacist, who submits the information to
ES/Medco. If a coverage review is necessary, ES/Medco automatically notifies the pharmacist, who in turn tells you that the prescription needs to be reviewed for prior authorization.
You, the pharmacist, or your doctor may start the review process by calling ES/Medco toll-
free at (800) 753-2851, 8 am to 9 pm, Eastern Time, Monday through Friday.
ES/Medco sends your doctor a fax form, requesting more information. After receiving the
necessary information from your doctor, ES/Medco sends you and the doctor a letter (usually within two (2) business days), confirming whether or not coverage has been approved.
If coverage is approved, you simply pay the normal co-payment for the medication. If
coverage is not approved, you will be responsible for the full cost of the medication. If appropriate, you can talk to your doctor about alternatives that may be covered. (You have the right to appeal the decision
. Information about the appeal process will be included in the letter that you receive
If your plan has a limit on the amount of medication covered, your
pharmacist will fill your prescription up to the amount allowed. If the prescription exceeds the amount covered by your plan, ES/Medco will tell the pharmacist whether a review might help you obtain coverage for the additional amount.
Through your mail-order pharmacy, ES/Medco By Mail:
You mail the prescription to ES/Medco. If a coverage review is necessary, ES/Medco calls your doctor to start the review
process. After receiving the necessary information from your doctor, ES/Medco sends you and the doctor a letter (usually within two (2) business days), confirming whether or not coverage has been approved.
If coverage is approved, you receive your medication and simply pay the normal
co-payment for the medication. If coverage is not approved, the prescription is returned to you. (You have the right to appeal the decision. Information about the appeal process will be included in the letter that you receive.)
If your plan has a limit on the amount of medication, then ES/Medco will
only dispense the amount allowed. ES/Medco will send you a statement that explains the limit and tells you whether a review might help you obtain coverage for the additional amount.
You can also visit ES/Medco a
After you log in, click “Price a medication” in the “Prescriptions & benefits” section. After
selecting a medication, see if there are any coverage notes. If you are a first-time visitor to our
website, take a moment to register. (Please have your member ID number as listed on your
ES/Medco ID card and a recent prescription number ready.)
Frequently Asked Questions
How much do I pay if the medication is approved?
If coverage is approved, you simply pay your normal co-payment for the medication. If coverage
is not approved, you will be responsible for the full cost of the medication.
How do I find out more about medications requiring coverage review/prior authorization?
For more information or a detailed listing of medications, please visiand click on “Drug information” in the “Prescriptions & benefits” section. If you are a first-time
visi take a moment to register. (Be sure to have your member
ID number as listed on your Medco ID card and a recent retail or ES/Medco By Mail
prescription number handy.) Or call ES/Medco Member Services at (800) 230-0508. Who approves the coverage review?
ES/Medco will contact your doctor to find out why the nonpreferred medication is needed.
ES/Medco will make a determination, approval or denial of the coverage, based on information
received from the doctor. If coverage is approved, you simply pay your normal co-
payment/coinsurance for the medication. If coverage is not approved, you will be responsible for
the full cost of the medication or, if appropriate, you can talk to your doctor about alternatives
that may be covered. (You have the right to appeal the decision. Information about the appeal
process will be included in the letter that you receive.)
When is a coverage review not approved?
The most common reason for a denial is that a doctor does not respond to the coverage review
request. What happens if I don’t obtain a coverage review before filling my next prescription/refill
for the nonpreferred medication?
The prescription will be stopped, and you’ll be informed that a coverage review is
needed. Your options include paying 100 percent of the cost, waiting for a coverage review, or
trying an over-the-counter (OTC) product, if applicable.
At ES/Medco By Mail:
The prescription will be stopped, and a ES/Medco pharmacist will reach
out to your doctor for a coverage review. If your doctor authorizes the switch, the new
medication will be dispensed and a letter will be sent to you. If a coverage review is approved,
the medication will be dispensed as written. If a coverage review is not approved, your options
include paying 100 percent of the cost or trying the over-the-counter (OTC) product if
ES/Medco will not switch a medication without approval from the doctor.
How long does a coverage review take to complete?
The time needed to complete the coverage review depends on your doctor’s response to
ES/Medco’s request. What if I don’t agree with the coverage review decision?
You can file an appeal with ES/Medco at 8111 Royal Ridge Parkway, Irving, TX 75063 Specialty Drug Access Program
Specialty medications are drugs that are used to treat complex conditions, such as cancer, growth
hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis, and
rheumatoid arthritis. Whether they’re administered by a healthcare professional, self-injected, or
taken by mouth, specialty medications require an enhanced level of service.
To get the most from your prescription drug benefit, purchase your specialty medications from
Accredo. If you use a pharmacy other than Accredo to purchase any of the specialty medications,
you will be responsible for their full cost. The services Accredo provides include:
Toll-free access to specialty-trained pharmacists and nurses 24 hours a day, 7 days a week
Expedited, scheduled delivery of your medications at no additional charge
Registered nurses available for in-home medication administration, when clinically
appropriate Necessary supplies, such as needles and syringes, provided with your medications
Refill reminder calls
If you have questions about specialty medications, please call Accredo at 1 800 501-7260.
Did you know that different people can respond to the same medication in different ways? That’s
because there are genetic differences between us that determine how well we respond to certain
drugs. Fortunately, new tests are available that measure how a person metabolizes certain drug
components. The results of these tests can give doctors important information about the right
drugs and doses for individual patients. Your prescription drug plan will pay for the Personalized
Medicine Program that helps you gain the full benefit of these tests.
The Personalized Medicine Program currently focuses on patients who are using warfarin,
usually for a heart condition, or tamoxifen for breast cancer. The conditions, drugs, and testing
covered by the program will change from time to time as new tests become available and are
included in the program.
If your medication history indicates that the testing could be beneficial for you, a ES/Medco
pharmacist will contact your physician to discuss the program. If your doctor agrees that the test
results would be helpful, you will be contacted by a pharmacist to let know that the testing is
available. If you agree to participate, you will receive a cheek swab test that you can administer
on your own. It’s as simple as rubbing a swab on your cheek and mailing it back in an envelope.
The results of your test will be sent to your doctor and to a ES/Medco pharmacist who has received special training in personalized medicine. The pharmacist is available to help your doctor interpret the results of your test. Of course, your participation is voluntary, and your doctor is still solely responsible for deciding which drug and dose is right for you. For up-to-date information on the conditions and drugs covered by the program, please call ES/Medco Member Services at (800) 230-0508. You can also call the Resource Center in Benefit Services at (607) 255-3936. 11/29/12
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