Group News Updates – May 2016


Medical Mutual New Specialty Drug Solution Option Helps Reduce Prescription Drug Spending while Keeping Members Safe

(Applicable to all business units, EXCLUDES Medicare Advantage and Medicare Supplement)

As part of our prescription drug program updates, MMO is implementing a new Specialty Drug Solution program. This program is intended to help keep our members safe, improve medication adherence, reduce waste and manage the cost of specialty medications.

The Specialty Drug Solution program will be our new corporate standard for all groups effective on or after July 1, 2016 (exceptions allowed for certain groups), and for existing groups renewing or making benefit changes on or after July 1, 2016. We also implemented this program on January 1, 2016, for all ACA (on- and off-exchange) individual policyholders.

The Specialty Drug Solution has two parts to it:

  1. Members are limited to a 30-day supply of specialty drugs

Limiting prescriptions to a 30-day supply of a specialty drug prevents waste if there is a change in therapy, such as if a member needs a different dosage to reduce side effects or due to changes in weight.

    • If the plan includes a specialty drug tier, members will be charged the 30-day retail cost-share amount (copay or coinsurance).
    • If the plan does not include a specialty drug tier, members will be charged the generic, preferred brand or non-preferred brand 30-day retail cost-share amount, depending on the drug.
  1. Members must fill specialty drugs at pharmacies in our Specialty Pharmacy Network

All specialty drug prescriptions must be filled at a contracted specialty pharmacy, other than transplant drugs, those used to treat deep vein thrombosis or HIV drugs. These drugs will still be subject to the member’s specialty drug cost-share tier, if applicable, and the 30-day supply limit. Our two contracted specialty pharmacies are currently Accredo Specialty Pharmacy, owned by Express Scripts, and Gentry Health Services, owned by Discount Drug Mart (for HIV, hepatitis C and injectable high-cholesterol drugs, such as Praluent and Repatha).

Specialty pharmacies can offer our members extra care and better outcomes, such as dedicated nursing and pharmacy staff who have additional training for certain diseases and drugs; free delivery of supplies (e.g., syringes and alcohol swabs, where applicable); monthly calls to check the member’s disease progress and schedule refills if needed; and more.

Implementation Timeline for the Specialty Drug Solution

The timeline to implement the Specialty Drug Solution is approximately two to three months. Because claims at retail stores and/or for more than a 30-day supply will deny, Express Scripts needs time to notify affected members. Please work with your Medical Mutual Sales representative for the required documentation and timing.

Source: Medical Mutual Broker Update 4/26/2016