Director's Message

Director's Message

Q-and-A: Medication changes in 2020

As Open Season comes to an end and our 2020 benefits approach, I want to take some time to discuss the prescription drug formulary changes that go into effect on Jan. 1. The Health Benefit Plan's goal is to help our members avoid any potential problems after the changes on that date. Other federal plans implemented these changes several years ago; however, we delayed the modification to our prescription benefit package. After careful consideration, the change to a standard formulary is now necessary for our plans as well.

Please keep in mind that making sure you have access to affordable medications is our priority. To keep costs low, the Plan covers a specific list of medications that may change occasionally. In this article, I would like to address some of the questions we have encountered and action you will need to take--while helping you understand exactly what you need to do if you have a prescription that is not on our formulary list.

Q: Why is there a change to the medications covered under my plan?
A: The Plan and CVS Caremark(R), along with CVS health Pharmacy and Therapeutic Committee, monitor your list of covered medications and make changes when lower-cost options become available. This helps both you and the plan save money throughout the year. The Plan, along with CVS Caremark, is committed to helping you get the most effective medications at the best price and keeping access to prescription medications affordable.

Q: How are decisions made about what medications are covered under my Plan?
A: There are often several medications, both generic and brand name, available to treat the same condition. Utilizing the less-expensive options available to treat your condition can create savings for both you and the Plan. However, determining the best covered option for you is up to you and your doctor. 

Q: How will I know what medications are covered under the formulary list?
A: You can find the list on our website under the 2020 benefits at nalchbp.org.

Q: Do I have to change to a different medication?
A: No. You always have the choice of continuing with your current medication; however, if you choose to continue taking the current medication, you will have to pay 100 percent of the cost.

Q: What if my doctor wants me to stay on my current medication?
A: If you doctor determines that none of the covered medications will work for your condition, your doctor can call 800-294-5979 to request prior authorization for your current medication. Please remember that prior authorization approvals are not guaranteed, so we recommend talking to your doctor about changing to a covered medication.

Q: Why will prior authorization be required (effective Jan. 1) for my current medication?
A: The Plan, along with CVS Caremark, is committed to helping you get the most effective medication to treat your condition at the lowest possible cost. CVS Caremark continually reviews medications, products and prices for the Plan. As part of this effort, some medications covered by the Plan require prior approval.

Q: How long does the prior authorization process take?
A: The average turn-around for prior authorization is 24 to 48 hours.

Q: How long will the prior authorization last for my medication?
A: The prior approval will last from the date the medication is approved for up to one year.

Q: What happens if I do not receive prior authorization for my current medication?
A: If you fill your prescription without prior authorization, you will pay 100 percent of the cost of the medication. Because approvals are given only after careful review of the necessary medical documentation by trained clinical staff, we recommend talking to your doctor soon about choosing a covered medication that does not require prior authorization to keep your cost down.

Q: What is the appeal process if a medication is not approved through prior authorization?
A: All appeals can be mailed to the following: CVS Caremark Prescription Claim Appeals MC109, P.O. Box 52084, Phoenix, AZ 85072-2084, or faxed to 866-443-1172.

Please let us know if you have other questions that we have not addressed. You can contact us at 888-636-NALC (6252).

In closing, I would like to take this opportunity on behalf of the employees and staff at the NALC Health Benefit Plan to wish you and your family a happy and safe holiday season and a happy New Year. Thank you for all the support and confidence you have shown in the Plan.

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Note: The information located in this article is only a summary of some of the NALC Health Benefit Plan benefits.  Detailed information can be found in the NALC Health Benefit Plan's official 2019 brochure (RI 71-009).  All benefits are subject to the definitions, limitations, and exclusions set forth in the official brochure.