Sandy Knoesel responds to questions re: Express Scripts list

From John Curry, August 7, 2008
Subject: The Express Scripts list...why can't retirees get it?

Sandy,

Thank you for this prompt reply.

I, and Medicare-aged retirees, will be awaiting the arrival of this list. I hope that, once issued, it is updated with changes as soon as they develop and, I do have a few additional questions:

You said, "The good news is this delay did not affect any coordination of benefits for Medicare Part B drugs at retail or mail." I am thinking of all those Medicare-aged retirees who enrolled in the Express Scripts program since January 1, 2008....the time when the newly contracted Express Scripts PBM handled STRS retirees' Rx needs....that's been seven months now... and counting. Since the Medicare Part B $0 copay for diabetic supplies has been practiced by many other pharmacies and some PBM's for a period of time, at least for four years now, I have to think that many STRS retirees have missed out on not only at least seven months plus of $0 copay under the Express Scripts contract but many years of $0 copay under previous STRS/PBM contracts. This amounted to quite a bit of money removed from the retirees' wallets as they had been purchasing diabetic test strips at not only at the lowest tier on the Rx copay scales but some test strips were even previously billed at tier 2 on the copay scale.

You said that, "Since the select prescription drugs" (actually, in this case, diabetic supplies and not pharmaceutical ingestible drugs) "that qualify for the $0 co-payment may change from time to time, enrollees should present both their Express Scripts ID card and their Medicare card to the pharmacist and the claim will automatically process under the lowest co-payment." My question to this statement is: Under the terms of our contract is Express Scripts allowed to change which Medicare Part B Rx's (actually diabetic supplies) they will supply at the $0 copay at their whim...possibly even each week or day or...is it a minimum longer period of time such as each month or six months? If so, just how long is this period of time if they are "locked into" a particular brand of Rx with a $0 copay? I realize that this question possibly may be entering into the realm of "trade secrets" and not allowed to be discussed publicly but....if not, could you please advise this time period that they are "locked in" to providing a particular diabetic Rx' supply with the $0 copay? If it is, in fact, a trade secret.... please advise and I will understand.

You said that, "Enrollees do not need to have a list to take advantage of the $0 co-payment. In addition, enrollees can always call Express Scripts and the member service representative can look up their medication to see if it qualifies for the $0 co-payment." In real life, STRS retirees (of Medicare B eligibility) do visit doctors offices and find that they are either border-line or actually diabetic (their first diagnosis) or, are currently purchasing diabetic test strips and, for one reason or another, the MD prescribes "another" brand of diabetic test strips and they are written an Rx for diabetic testing supplies "on the spot." Retirees do need the list and so does the doctor if the Rx is written "at that time." Otherwise, it is a "guessing game" as to whether a particular Part B item will or won't be covered by the $0 copay without a call to Express Scripts....a list would come in very handy....for both the MD and the retiree.

Another reason for a "list": If the retiree sends the mail order Rx for a particular diabetic supply to Express Scripts, and finds that it is a particular supply not covered by Express Scripts at the $0 copay then....a problem develops. The retiree is responsible for remitting the additional proper copay (which, in this case, now requires a credit card transaction and/or a personal check sent with the proper amount of copay) which can result in a delay for the retiree getting his/her diabetic testing supply.

While I have your ear I would also like to ask a question pertaining to a recent letter that was sent to my fellow retiree and CORE member, Shirlee Zerkel. The letter appears below: In this letter, you state that: "In developing the Medicare COB program at retail, staff was concerned with quality and safety issues when enrollees do not use their ESI prescription drug card. When the card is not used, Express Scripts cannot perform the safety review of prescription drugs to prevent any adverse interactions of drugs taken by enrollees. Consequently, the $0 copay at retail was established for specific Medicare Part B drugs." OK, I'm also safety conscious but...we are talking about prescription Medicare Part B "diabetic testing supplies" (test strips, meters, etc.) and, you state, that the staff is concerned that they possibly could cause "adverse interactions of drugs." I wonder if retirees are ingesting these testing supplies orally or....in some other body orifice? Sorry, I know this is serious business but, I couldn't resist that last sentence....one has to have a little fun in life, doesn't one? For retirees, fun doesn't seem to occur all that often anymore....especially with the current economy and the prohibitive cost of healthcare.....and especially to those STRS retirees who have to medically insure their spouses.

Once again, thank you for promptly addressing this issue.

John Curry an STRS retiree

Sandy Knoesel to Shirlee Zerkel, August 7, 2008
Subject: FW: Wow, a letter from Express Scripts!

Dr. Leone and Mrs. Zerkel: Here is the e-mail that was sent on July 31. I am sorry; but, it looks like the e-mail went to the wrong address for Mrs. Zerkel. Please let me know if you have any questions.

Sandy

Sandy Knoesel to Shirlee Zerkel, July 31, 2008
Subject: RE: Wow, a letter from Express Scripts!

Dear Mrs. Zerkel:

Dr. Leone received your e-mail and asked me to respond. We have corresponded with you many times during the past several years regarding these issues. We understand your frustration in 2004 because Caremark was unable to provide a program that coordinated Part B drug benefits with Medicare and retail pharmacies. In negotiating a contract with ESI, STRS Ohio and the other participating retirement systems insisted that ESI develop a program that provided COB at retail. While the $0 copayment offered by Rite Aid is not new to you, it is a new program for STRS Ohio, Express Scripts and Nations Health.

In developing the Medicare COB program at retail, staff was concerned with quality and safety issues when enrollees do not use their ESI prescription drug card. When the card is not used, Express Scripts cannot perform the safety review of prescription drugs to prevent any adverse interactions of drugs taken by enrollees. Consequently, the $0 copay at retail was established for specific Medicare Part B drugs.

Regarding the credits you described, staff has investigated every case that was brought to our attention regarding these credits. In addition, independent audits of the PBMs are conducted to ensure that the benefits are being administered correctly.

Thank you for sharing your concerns with us.

Sandy Knoesel

Sandy Knoesel to John Curry, August 7, 2008
Subject: RE: The Express Scripts list...why can't retirees get it?

Dear Mr. Curry:

Thank you for your e-mail concerning the list of select Medicare Part B prescription drugs eligible for a $0 copayment. Unfortunately, there was a delay in finalizing the design of the printed piece and this document will be ready for distribution by request early next week. We also plan to post the list to our Web site at that time.

The good news is this delay did not affect any coordination of benefits for Medicare Part B drugs at retail or mail. Since the select prescription drugs that qualify for the $0 copayment may change from time to time, enrollees should present both their Express Scripts ID card and their Medicare card to the pharmacist and the claim will automatically process under the lowest copayment. Enrollees do not need to have a list to take advantage of the $0 copayment. In addition, enrollees can always call Express Scripts and the member service representative can look up their medication to see if it qualifies for the $0 copayment. Please let me know if you have any other questions.

Sandy Knoesel