MN Advantage Health Plan 2008  - Questions & Answers

Who is the new Pharmacy Benefits Manager (PBM) for my MN Advantage Health Plan?
NAVITUS is the new PBM starting January 1, 2008. Their claim is that they are “committed to lowering drug costs, improving health and delivering superior service in a manner that instills trust and confidence.”  Learn more about them at www.navitus.com. 

What pharmacies can I use under the new SEGIP Pharmacy Benefit Manager, Navitus?
A complete list of pharmacies can be found at: www.navitus.com/Network%20Listing/pharmacy_complete.pdf and a list of the major pharmacy chains can be found at: www.navitus.com?Network%20Listing/pharmacy_majorchains.pdf

What will my drugs cost me through Navitus?
There are now three tier prices for drugs: Tier 1 $10; Tier 2 $16; and Tier 3 $36.  To find out what tier a specific drug is assigned to go to: www.navitus.com/Formulary%20Document%20Library/MN_Formulary.pdf

How do I file a complaint or appeal the pricing of a specific medication for my use?
When you have a concern about a benefit please call Navitus Customer Care center toll-free at 866-333-2757.  When you must take a specific medication that has the higher cost you may (one time only) seek a “co-pay lowering.”  Fax the following information to: Navitus Health Solutions, 920-831-1930, Attn: Appeals Department or mail it to Navitus Health Solutions, Attn: Appeals Department, 5 Innovation Court, Suite B, PO Box 999, Appleton, WI 54912-0999. This is a process with steps including the following:

1)  Identifying the Rx you need, its dose and duration
2)  Identifying the alternatives Navitus lists for that Rx
3) Provide medical documentation (written request from the member or physician in addition to chart documentation) addressing what alternatives were tried and failed, the reason for not trying the alternative, the side effects of ineffectiveness of any alternative tried

Will mail order, where I can get three months of a prescription for two months cost, still be available?
Yes, provided by WellDyne.  They phone number is 1-866-490-3326.  Obtain the Mail Service Order Form at: www.navitus.com/Pages/WellDyne.aspx

Do some prescription drugs require prior authorization from Navitus?
Yes.  Navitus has identified a limited number of prescription drugs that require prior authorizations.  Prior authorization is initiated by the prescribing physician on behalf of the member.  More information about which medications require prior authorization, as well as the prior authorization process, is available at: www.navitus.com/Pages/PriorAuthProcess.aspx

Do I need to use a specific pharmacy if I am on a "specialty" medication?
If you are on a specialty medication, Navitus, in conjunction with SpecialtyScripts Pharmacy, has designed a new specialty pharmacy program, Navitus Specialty Rx, to help members and their prescribers with specialty pharmacy needs.  Medication available through this program is denoted with “SP” in the Navitus Formulary.

NAVITUS –The Advantage Health Plan Pharmacy Benefits Manager wants to inform health plan members to contact their customer care call centers with questions or problems resulting from the change in pharmacy benefits managers for those in the Advantage Health Care Plan.  Their contact information is: www.navitus.com or 1-866-333-2757.  Many individuals have not filled prescriptions under NAVITUS yet.  Some are finding significant cost changes.  The first call should go to NAVITUS.  Please inform MGEC of unresolved issues.  Here are a few notes from a recent meeting with a NAVITUS representative:

·        If member does not have their NAVITUS card, the pharmacist can call Navitus Customer Care and get the prescription filled.

·       NAVITUS seeks to have customers take the lowest cost drug therapy that works.  Sometimes this means taking a generic versus the brand drug.  Other times it means trying an alternative drug that is designed to address the same problem as the brand drug.  Individuals need to be active participants with their doctors, pharmacists and Pharmacy Benefits Managers in making the right choice for their needs.

·      “Dispense as Written” – ability for member to get a branded drug instead of a generic one.  There is a penalty if either the physician wants the brand drug (coded DAW1) or if the member wants the brand drug (DAW2).

·      A “brand drug” is a specific drug by one manufacturer.  A patent gives the manufacturer 17 year’s rights to make that specific drug.

·      A “generic drug” contains the same drug composition as the original brand drug.

·      “Formulary drugs” simply refer to drugs on the approved drug list of the Pharmacy Benefits Manager.

·      In determining if NAVITUS will cover a drug and at what cost level they ask the question, “What makes sense clinically?”  NAVITUS wants to see a couple alternatives being tried beside the higher priced brand drug.  If there is a prior authorization from BCBS, HP, or Preferred One, NAVITUS will honor that prior authorization for brand drug.  It will still be at Tier 3 cost.  Without the authorization, the patient must pay the difference between the actual drug cost and the cost level co-pay.  Example of price difference: Prozac ($5) versus Fluoxetine ($.15) per pill.

·      If someone has already been through “step therapy” – let NAVITUS know that the person has already been through it.  In many cases, the documentation is already out there that can be made available to NAVITUS.  What have you used prior to taking the drug?  If something else was tried and now another drug is used that indicates step therapy has been met.

·      “Prior Authorization” – 48 hour turnaround – a diagnosis is needed and a disease specialist will be required to determine the prescription is correct.    They won’t just take the prescription from a general family internist.

·      “Appeal” – a prior authorization has already been made.  There is an appeals meeting every two weeks.  There could be a 30 day lag.  Everyone is approved to continue the drug until the appeal is completed.

·      Co-pays are different at different pharmacies.  Some pharmacies charge the customer the full co-pay, regardless of the actual cost of the drug (such as Walgreens and CVS).  Others will charge members less, if the actual cost of the drug is less than the co-pay.  SEGIP should promote to members information about the pharmacies where the costs might be less.  The NAVITUS customer care line can tell someone which pharmacy will sell for less and which drugs might cost less than the plan co-pay.   Or members need to ask the pharmacist what the “cash price” is for a drug.  They will learn what drugs cost less than the co-pay.