The Trusts administered by Christian Brothers Services have chosen Express Scripts, Inc. to manage the prescription drug benefit for our participants. With Express Scripts’ sophisticated dispensing technology, management programs, and mail-order pharmacies, Trust participants are provided with access to high-quality prescription drugs and services aimed at improving outcomes and controlling spend.
Express Scripts by Mail
In the mail-order pharmacies, quality process activities, as well as customer satisfaction, are driven by performance measurement in four key areas: Compliance, Quality, Service, and Cost. Express Scripts and each of its mail-order pharmacies are fully accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and are diligent in adhering to all applicable standards of that organization. When you register at mycbs.org/health and click on My Prescription Drugs, you will have instant access to your prescription history, be able to price alternative medications, locate participating pharmacies and check reorder status.
Coverage management will be managed by Express Scripts. There is nothing required of the participant as the program will automatically be implemented when certain medications are prescribed. If a prescription requires coverage management, the prescribing physician will be consulted to provide additional information before the medication can be filled through the benefit plan.
Prior authorization monitors prescription drugs to ensure participants are getting the medications that are suitable for their intended use and the patient has met certain criteria, such as age, sex, or condition necessary to ensure the effectiveness of the medication.
Step therapy is a managed approach to prescription drugs intended to control costs and mitigate risks posed by certain medications. A review process is followed to make sure participants have tried other, lower first level medications that could work and determines if an alternate therapy course or treatment is appropriate.
Quantity limitations promote the safe and appropriate use of medications intended for a limited duration of use and minimize potential waste of expensive medications. These quantity restrictions are based on product labeling or clinical guidelines and are subject to periodic review and change.
All Trust prescription drug plans include a formulary list. At its most basic level, formularies are lists of drugs, generic and brand name, which offer the greatest overall value to plan participants.
Medications indicated on the formulary list are typically grouped into three tiers: generic, preferred brand, and non-preferred brand. Formulary management enables participants and their physicians to choose clinically appropriate and cost-effective drugs for specific conditions. The tier the medication falls under will determine the participant’s portion of the drug cost.
The Trust plans adhere to Express Scripts’ National Preferred Formulary. Medications not included in this formulary are not covered by the plan and can be found on the exclusion list.
The term “generic” holds many connotations in the minds of consumers—many of them negative. When it comes to generic prescription drugs, the U.S. Food and Drug Administration (FDA) requires all generic drugs to have the same quality and performance as the brand name equivalents.
More than half of the prescription drugs available today have a generic option for consumers. Most prescription drug plans, including the plans administered by Christian Brothers Services, have a lower co-payment for generic medications because the cost of generic medications is considerably less expensive than brand name medications.
Member Pays the Difference
The Member Pays the Difference management program discourages the use of multi-source brand name drugs when suitable generic equivalents are available. If a generic is available and the brand medication is filled, regardless of how prescriptions are written, the participant will pay the brand copay and the difference between the brand and generic cost.
A physician appeal protocol through Express Scripts is in place that will allow participants to fill the brand name at the brand copay if they cannot take a generic due to reasons supported by the prescribing physician.
SaveonSP works in conjunction with the EBT’s current pharmacy program through Express Scripts. Participants will receive their specialty medications through Accredo, Express Scripts’ specialty mail-order provider. SaveonSP will leverage manufacturer’s copay assistance programs to provide both savings to the participants and the Plan.
SafeGuardRx (coming 1/1/2020)
Six out of every 10 adults in the U.S. have a chronic condition. Chronic conditions not only take a toll on someone’s health, but they also take a toll on annual healthcare costs. The SafeGuardRx program from Express Scripts is a better way to help plans and members manage the costs of chronic conditions, such as Diabetes Care, Pulmonary Care, Migraine Management, and Rare Diseases.
Retail Refill Allowance
Most plans limit the number of fills at a retail pharmacy to the initial fill and two subsequent refills and then request that you convert the script to mail order. Participants may continue to fill at a retail pharmacy, however, they will assume more of the cost of the medication.
Smart90 (coming 1/1/2020)
Smart90 Prescriptions gives the participant the option to fill a 90-day maintenance prescription at a Walgreens (or its affiliates) in lieu of using Express Scripts mail-order delivery program. Smart90 gives the participant flexibility if they prefer not to have their 90 days of medication delivered to their home.
The RationalMed® program protects the safety of participants who may have prescriptions from more than one physician or pharmacy. RationalMed® relies on a database that checks a participant’s prescription activity against clinical evidence to avoid adverse reactions and potential drug to drug interactions.