New plan harmonizes
note: This article is the fourth in a
series submitted by the Benefits Office
on the Universitys new prescription
drug plan, which begins Jan. 1, 2003.
Previous articles have announced the Universitys
decision to consolidate pharmacy purchasing
under a single Pharmacy Benefit ManagerAdvancePCSand
to carve out the prescription drug benefit
from medical plans. This article looks
at drug harmonization decisions that affect
all plan members, regardless of their
medical insurance. The next article in
the series will discuss preferred and
non-preferred drugs and the plans
new mail order program.
One of the advantages of consolidating
the pharmacy benefit for the Universitys
eight medical plans is that members of
those plans now will have consistent coverage
for prescription drugs.
While the pharmacy benefits within medical
plans currently cover most commonly prescribed
drugs, some disparities exist between
the plans coverage and rules. For
example, some insurers do not cover psychiatric
drugs and oral contraceptives and devices.
The new plan will harmonize
and expand drug coverage for all members.
Beginning Jan. 1:
- Members of BlueCross BlueShield of
Michigan/United of Omaha and their dependents,
as well as retirees and their dependents,
will have coverage for psychiatric drugs.
- Members of Care Choices, CMM, and
BCBSM/United of Omaha, in addition to
all other U-M medical plans, will have
coverage for oral contraceptives and
- The new plan covers fertility medications
for patients through age 44, up to $5,000
per lifetime per family.
- Diabetic insulin, needles and syringes
are covered with no co-payment, and
other diabetic suppliesalcohol
swabs, testing strips, blood glucose
monitors and lancetswill be covered
at regular co-payment levels.
- Smoking cessation support drugs will
be covered with a 90-day supply per
- Some self-administered injectable
medications, such as insulin, allergic
emergency kits, anti-migraine agents
and B-12, will be covered.
The University has taken a strong
stand with insurance carriers in saying
that we believe everyone should have equal
access to prescription drugs, says
Jeoffrey Stross, professor of internal
medicine and chair of the U-M Pharmacy
Benefit Advisory Committee (PBAC). I
think this is very good news for the entire
Drugs excluded from coverage under the
plan include experimental or unproven
drugs, over-the-counter medications, cosmetic
drugs, weight-loss drugs and fluoride
dental products. Our pharmacy plan,
like most others, excludes weight loss
drugs because of significant side effects.
The risk-benefit ratio is not acceptable,
A complete list of excluded drugs, as
well as the Universitys Preferred
Drug List (PDL), recommended to physicians
for prescribing, will be available on
the new cobranded Web site, http://umich.advancerx.com,
which will be up by Oct. 1.
Approval of a new drug by the federal
Food and Drug Administration does not
guarantee coverage by the plan. New drugs
will be covered after the Universitys
Pharmacy Benefit Manager, AdvancePCS,
and the PBAC have thoroughly reviewed
those medications for safety, efficacy
and cost effectiveness. This process generally
takes one to two months, according to
Formed last June, the PBAC is a committee
of physicians, pharmacists and Benefits
Office staff members who develop and update
the PDL and report to the U-M Pharmacy
Oversight Committee. The committee is
a faculty and staff group that advises
the University executive officers on implementation
of the new drug plan.
The University has decided to cover
prescription drugs that support smoking
cessation in view of the high mortality
rate associated with tobacco use, says
Stross. The medical costs of smoking-related
disease are far greater than the pharmacy
costs of drugs like Zyban, he says. For
years, doctors were prescribing Zyban
to smokers as an anti-depressant because
their plans did not cover the drugs their
patients really needed, he says.
The decision to cover insulin, needles
and syringes at zero co-payment for diabetics
also is an enlightened approach, Stross
says. We want to eliminate every
possible barrier to treatment of diabetes.
Access to insulin is critical to preventing
complications from the disease,
While fertility drugs are expensive,
the University will cover them up to $5,000
lifetime per family. The PBAC based the
limit on data that shows $5,000 would
cover costs for about 90 percent of people
who need those medications.
Under the new plan, a few drugs will
require a prior authorization procedure.
If physicians prescribe any medications
on the Prior Authorization list, they
must contact AdvancePCS and provide clinical
information to meet pre-approval criteria.
The physician may have to verify medical
necessity before the plan pays benefits
for the drug. The Prior Authorization
list will be posted and updated on the
U-M/AdvancePCS Web site starting in October
Similarly, physicians must provide documentation
to support a medically necessary
appeal if the plan denies coverage of
a drug. No appeals will be accepted for
a lower co-payment level. The University
will provide the criteria to apply for
an appeal to AdvancePCS and will review
all data provided for appeals.