Smoke Signals 5
JUNE 15, 2007
Tribal Member Health Plan To Implement Exclusive Home Delivery
Program (Mandatory Mail Order) And Step Therapy Programs
Effective July 1, 2007, all participants receiving the self-insured medical
payment plan benefit administered by UMR will be required to comply with
the Exclusive Home Delivery Program and Step Therapy programs. The two
programs will allow the Tribe to control pharmaceutical costs so we can continue
to provide prescription drug coverage for Tribal members and spouses.
Step Therapy is a program designed for people who take prescription
drugs regularly to treat ongoing medical conditions, such as arthritis and
high blood pressure. The program is a new approach to getting patients
the prescription drugs they need, with safety, cost and most importantly,
their health in mind.
Home Delivery Program. To find out if a specific drug is considered a
maintenance medication, please call Express Scripts using the toll-free
number on your member ID card (800-892-5143).
Doea thia mean my preacriptions are not covered anymore?
No, it just means that the Tribe will cover only two one month supplies
of your maintenance medications from a local participating pharmacy.
After you've used these two one month supplies, you will need to order
the medication from the CTGR Wellness Pharmacy or Express Scripts
Pharmacy to receive coverage.
In Step Therapy, drugs are grouped into categories based on cost.
Front line drugs Step 1 are generic drugs
proven safe, effective and affordable. These
drugs should be tried first because they can
provide the same health benefit as more ex
pensive drugs at lower cost.
Back-up drugs Step 2 and Step 3 drugs
are brand name drugs. There are lower-cost
brand drugs (Step 2) and higher-cost brand
name drugs (Step 3). Brand name drugs
always cost more.
FAQ's:
What are generic druga?
Even though generics usually have a different
name, color andor shape, a generic alternative
has the same chemical makeup and same effect
in the body as the original brand-name drug.
Generics, have been around for a long time,
have been rigorously tested and the US Food
& Drug Administration (FDA) has approved
them as safe and effective.
What happens at the pharmacy?
The first time a patient submits a prescription
that isn't for a front-line drug, the pharmacist
should inform the patient that the Tribe's plan
uses Step Therapy. This simply means that if
the patient would rather not pay full price for
the prescription drug, they must first try a front
line drug. To receive the front-line drug, the
pharmacist or patient can call the prescribing
doctor and request a new prescription.
How do I know which front-line drug my
doctor should prescribe?
Patients can take a list of the front-line drugs to his or her doctor. Ex
press Scripts and The Tribe's Risk Management department can assist
in obtaining these lists.
What if I've already tried the front-line drug on the list?
If a patient has already tried a generic drug, can't take a generic drug
for some reason (allergic reaction) or the doctor decides that for medical
reasons, that a brand-name drug is needed, brand-name drugs will be
covered. If one of these situations applies, the patient's doctor can request
an override so the patient can take a back-up (brand-name) drug.
How will I know I am on a maintenance medication before I go
to my local pharmacy for a refill?
Anytime you fill a maintenance medication
at your local pharmacy that is included in
your Exclusive Home Delivery Program you
will receive a letter from Express Scripts. This
letter will:
Explain your Exclusive Home Delivery ben
efit. Identify any of your current prescriptions that
may be affected.
Inform you that the Tribe will cover only
two fills of these medications from your local
pharmacy.
The letter also explains the benefits of
your Exclusive Home Delivery Program and
includes information on how you can order
your maintenance medications from the CTGR
Wellness Pharmacy or Express Scripts.
How does the Express Scripts Pharmacy
work?
The Express Scripts Pharmacy specializes in
helping patients save time and money. Last
year alone the Express Scripts Pharmacy filled
more than 38 million prescriptions for mainte- ,
nance medications.
Every prescription is filled and delivered us
ing a safe, reliable process. For example:
Two registered pharmacists check every new
prescription.
Your medication is delivered in a plain,
weather-resistant package. This protects the
medication and ensures your privacy.
You receive information about safety issues,
side effects and drug interactions.
Pharmacists are available 24 hours a day to answer your questions.
My doctor is "trying out" this medication with me, so I don't know
if III be using it long-term. Do I still have to use the Expresa Scripta
Pharmacy to fill this prescription?
No, not at first. The program is designed to let you and your doctor "try
out" each new maintenance medication and decide if it's a good long-term
therapy for you. In fact, if your doctor is having you try different doses of
the same drug, the Tribe will cover each dosage up to two times from a
local participating pharmacy.
A Health Newsletter
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For mora health news, check out the first issue if
Pathway To Health inside this issue.
Exclusive Home Delivery Program is a program allowing members to
receive maintenance medications in a reliable, convenient way, while
keeping plan costs down. A maintenance medication is a prescription
drug that treats an ongoing condition such as high blood pressure. Un
der this program, you can get up to a one-month supply of maintenance
medication two times from a local pharmacy. After that, the Tribe will
cover the medication only if you order it from the Tribal pharmacy or
Express Scripts. After two months of taking the maintenance medication
and your doctor decides that this is a good long-term therapy, to continue
receiving the medication you must use the CTGR Wellness Pharmacy or
Express Scripts Pharmacy. By using one of these two pharmacies, you'll
save money on your co-payments for maintenance medications. Plus, you'll
receive free home delivery of your medication, up to a 3-month supply of
medication with each order and 24-hour access to a pharmacist at Express
Scripts Pharmacy.
If you decide not to use the CTGR Wellness Pharmacy or Express Scripts
Pharmacy you can still get your maintenance medication from a local
pharmacy, but you will be required to pay the full cost of the drug.
FAQ's:
Aren't most drugs "maintenance medications?"
Not necessarily. Many drugs are for short-term conditions. For ex
ample, your doctor might prescribe a fifteen day medication for an
infection. You should always get these types of medications from a
local participating pharmacy. Some medications such as controlled
substances would not be considered maintenance by your Exclusive
How do I start using the CTGR Wellness Pharmacy or Express
Scripts Pharmacy?
There are three easy ways to start using home delivery:
1. Contact CTGR Wellness Pharmacy or Express Scripts and ask about
home delivery. CTGR Wellness Center Pharmacy, phone 503-879-2013
1-800-775-0095 or fax 503-879-2030, or refill line at 503-879-2342. Please
specify mail order or pick-up and always call 7 days in advance.
. 2. Express Scripts at 800-892-5143 n
3. Online Express Scripts Pharmacy: Visit www.express-scripts.com
get started and follow the instructions to get prescription home delivery.
Submit your request online, and the Express Scripts Pharmacy will do
the rest.
By Mail Express Scripts Pharmacy
1. Ask your doctor to write a prescription for up to a 90-day supply of
your medication (plus refills for up to one year, if appropriate).
2. Complete a Home Delivery Order Form. If you don't have an order
form, you can print one at www.express-scripts.com. Or simply request
one by calling the toll-free number on your member ID card.
3. Mail your order form and your prescription to the address on the
form.
Once you move your maintenance medication prescription to the CTGR
Wellness Pharmacy or Express Scripts Pharmacy one time, your prescrip
tion drugs are delivered to your home and you order refills only three
times per year instead of every month, and you renew your prescription
only once per year.