Aug. 26, 2003
This column on employee issues is prepared by the staff of the Employee Compensation and Benefits Services office.
What is the new pharmacy benefit for state group health?
In July 2003, the Group Insurance Board authorized the Department of Employee Trust Funds (DETF) to contract with a Pharmacy Benefits Manager (PBM) to provide pharmacy benefits services to all State of Wisconsin group health insurance participants. Beginning Jan. 1, 2004, all participants will receive their pharmacy benefits from the PBM, Navitus Health Solutions (Navitus). Other than having a separate identification (ID) card, many participants will not notice a change.
What are the benefit levels?
As part of the new prescription drug benefit, a three-level co-payment structure for pharmacy benefits will be implemented as of Jan. 1, 2004, and is as follows:
Co-payment per formulary prescription drugs: $5
Co-payment per formulary prescription drugs: $15
Co-payment per non-formulary prescription drugs: $35
*Level 1 consists of most generic and certain low-cost brand-name drugs.
**Level 2 consists of preferred brand-name and certain higher-cost generic drugs.
***Level 3 co-payments do not apply toward the annual out-of-pocket maximum, which is $300 per member and $600 per family.
What is a formulary and how is it developed?
A formulary is a list of preferred prescription drugs established by a committee of physicians and pharmacists that is determined to be medically effective and cost-effective. The formulary will be developed by a Pharmacy and Therapeutics Committee, which includes a statewide group of physicians and pharmacists. Drugs are evaluated on the basis of effectiveness, side effects, drug interactions, and then cost. On a continuous basis, new drugs are reviewed to make sure the formulary is kept up to date and that patient needs are being met.
Do health plan providers continue to write the participant's prescriptions?
Yes. The PBM will work with all health plans to educate physicians on the new uniform formulary and how to obtain any necessary prior authorizations for prescription drugs. If a member has a current prescription that has been filled since June 2003, the information will be provided to the PBM via the member's health plan, and, in most cases, the balance of the prescription will be filled by a PBM pharmacy after Jan. 1, 2004.
How will I use the program?
Subscribers will receive two ID cards for 2004, one from their heath plan and one from Navitus. When filling prescriptions, members will need to present their Navitus ID card to the pharmacist. ID cards will be mailed in December 2003.
Who do I contact for more information?
Beginning Oct. 1, you can contact Navitus: www.navitushealth.com, (866) 333-2757 (toll free), or Navitus Health Solutions, 5 Innovation Court, Appleton, WI 54912.
For more information: Visit the DETF Web site at http://etf.wi.gov