At the October meeting of the Oklahoma State and Education Group Insurance Board (OSEEGIB), the new maintenance pharmaceutical plan for active and pre-Medicare retirees was discussed and changes were made to accommodate members in the rural areas.
“While OPEA supported the savings in the new plan, we were pleased that changes were adopted to make it easier for rural members to access pharmaceuticals in the community,” said OPEA Executive Director Sterling Zearley.
The new HealthChoice maintenance pharmaceutical plan allows members to receive maintenance drugs at a lower cost from pharmacies that participate in the new maintenance network or through the mail order plan.
The HealthChoice maintenance network benefit is limited to maintenance medications. These are medications that the member uses on a routine basis, not medications such as antibiotics to treat an acute illness. Under the new benefit design members will be allowed to get three refills of a thirty day supply at any network pharmacy. After the third refill, the member will need to obtain refills through the maintenance network pharmacy to avoid higher coinsurance.
The pharmacy maintenance network will save the HealthChoice plan an estimated $9 million per year. This is based on a lower reimbursement rate through contracted maintenance network pharmacies. All retail pharmacies can become part of the maintenance network. This change only reduces the profit for maintenance medications for active and pre-Medicare participants. The Medicare supplemental plan is not included in the network. Medco is soliciting those network maintenance contracts now and has already contracted with Walmart and CVS.
“OPEA has not opposed the new maintenance pharmaceutical network because it saves the insurance plan $9 million,” continued Zearley. “The Association has worked very hard to preserve the state employee benefit allowance over the past ten years and doesn’t believe it is in the interest of state employees to oppose reforms that do not change the plan structure, but save the state money. Because of this change, HealthChoice rates did not increase this year.”
If the pharmacy plan had not been implemented the HealthChoice premiums would have increased by:
$68.40 per year for employee
$102.96 per year for covered spouse
$36.48 per year for those employees covering once child
$52.56 per year for those employees covering more than one child
That’s $224 for a family of four.
OSEEGIB has been working with OPEA and other constituent groups identify and address issues with the new plan. At the October Board meeting, two changes were made to the maintenance network plan.
In the first change, after a member obtains the third refill of a maintenance medication at a retail pharmacy that does not participate in the maintenance network, the coinsurance for maintenance medications shall be the maintenance network copayment PLUS the differential in contracted rates between retail and the maintenance network. This eliminates the higher copay of 50 percent of the cost of the medication that was previously adopted by the Board in August.
The second change allows Medco to offer a higher reimbursement for pharmacies to join the maintenance network if those pharmacies are located more than 15 miles from a maintenance network pharmacy.
It is important to remember that, every member has the right to utilize a network retail pharmacy for maintenance medications and receive an insurance benefit – even if the pharmacy does not sign the maintenance network contract. If the member chooses to use a pharmacy that does not participate in the maintenance network, the member will incur additional coinsurance.
“Some members have called the OPEA office concerned about their local pharmacy losing money with this plan,” concluded Zearley. “While everyone wants businesses to thrive in our communities, OPEA’s priority must be the maintaining a quality, insurance program at the lowest possible cost for state agencies and employees.”
