2020 Changes to UMP Prescription Drug Formulary

2020 Changes to Uniform Medical Plan (UMP) Prescription Drug Formulary

by Carol Dotlich, RPEC Executive Board Member

The Public Employees Benefit Board (PEBB) passed the following resolution at their April 24th meeting:

Resolved that, beginning January 1, 2020, contingent upon approval of a value formulary resolution by both the PEB an SEB Boards, all Uniform Medical Plans plans require the use of a value-based formulary and :

• Non-formulary drugs are covered only when medically necessary and all formulary drugs were ineffective or are not clinically appropriate for that member, and
• Multi-source brand-name drugs, including those in refill protected classes, are covered only when medically necessary and all formulary drugs have been ineffective or are clinically inappropriate for that member, and
• Members who have been taking a non-formulary dug are required to switch to the formulary drug, unless:
  • they receive or have already gone through the exception process and been approved, or
  • their drug is with one of the refill protected drug classes which include:  antipsychotics, antidepressants, anti epileptics, chemotherapy, antiretrovirals, immunosuppressives, and immunomodulatory/antiviral testament for Hepatitis C.

Information provided to the board indicated that 20% of UMP users are retirees and 40% of the drug spend is retirees.  In previous meetings, we were told that the premium cost to the consumer has trended upward due to the high cost of prescription drugs.  The purpose of the resolution is to try to control drug costs.

Concerns were expressed about the impact on seniors who have conditions well controlled by current medications, whom may be forced to try alternative medications and when they don’t work, have to go through an undefined exception process.

The reasons Health Care Authority (HCA) Staff have stated for this change was necessary are as follows:

• Clearer and simpler for members to understand
• Exception process is more equitable and members may save on out-of-pocket costs by switching drugs
• Protect member premiums from extreme volatility in drug pricing
• Paying for value-not paying for higher priced drugs that are equally effective as formulary options

HCA will begin reaching to current UMP subscribers who are taking non-formulary drugs to inform them of the changes and encouraging them to begin the process of working with their provider to switch to alternative drugs or begin the exception process.

The Exception Process:

If a UMP member is prescribed a drug that is not on the formulary, the member will need to pay the full cost of the drug. Members should talk to their physician about prescribing an alternative drug that is on the formulary. However, if the member has tried all the alternative drugs and none are found to be effective, or if the alternatives are found to be not medically appropriate, the member can request an exception.

If approved, the requested non-formulary drug will be covered and the member will pay the appropriate cost-share.

Exception Process

1. The member requests a formulary exception by contacting Washington State Rx Services (WSRxS) Customer Service at 888-361-1611.
2. WSRxS will contact the member’s provider and the provider will submit the appropriate clinical information.
3. WSRxS’ clinical team will review the submitted information to determine if the formulary alternatives the member used were ineffective or are not clinically appropriate.
4. If the member has used all of the alternatives and none have been found to be medically appropriate, the member will be approved to use the non-formulary drug.
5. If the exception is not approved, the member will be directed toward the appropriate alternatives on the formulary, or the member may pay the full cost for the non-formulary drug.

RPEC members who may be impacted by these changes should talk to their providers and begin the process of either switching medications or beginning the exception process prior to the end of the year to avoid complications in when the policy takes effect on January 1, 2020.