Express Scripts Updates and Medicare Notice

Express Scripts Updates and Medicare Notice

Opioid Management

The Opioid Epidemic was brought on by alarming opioid-related statistics in recent years. In 2016 alone, 115 people died each day from a prescription pain killer overdose. Several prescriptions drug companies have implemented drug abuse regulation programs to combat the epidemic. Express Scripts, the A&M System’s prescription drug insurance provider, has been nationally recognized for its active fight against opioid abuse.

In response to the epidemic, restrictions are in place for the purchase and use of opioid medications through the prescription drug plan. As of September 1, Express Scripts (ESI) has added the following conditions to its Opioid Management program:

  • Adults beginning opioid therapy are limited to a 7-day supply for each of their first four fills, and require a Prior Authorization (PA) to exceed 28-days’ supply in a 60-day period.
  • Pediatric patients’ opioid therapy is limited to a 3-day supply for each of their first four fills and will require a PA to exceed 12-days’ supply in a 60-day period.
  • Prior authorization is required for members starting on opioids who accumulate a daily morphine- equivalent dose greater than 90MME.
  • Existing opioid users will continue to be limited to 200MME without a prior authorization
  • Attestation of treatment plan or pain contract and assessment of co-prescribing of naloxone is required to exceed 200MME
    • Additional documentation is required to exceed 600MME
  • New Physician Care Alerts
    • Alert when patient with a mental health prescription is prescribed an opioid
    • Alert when patient with a prenatal vitamin prescription is prescribed an opioid
  • New Patient Support
    • Outbound phone calls from ESI’s Therapeutic Resource CenterSM (TRC) pharmacists to support members on Medication-Assisted Therapy
  • Bringing additional awareness to patients by providing suicide, mental health and addiction hotline resources for members needing someone to talk to on select member-facing materials


How Automatic Refills Work with Express Scripts

When enrolling an eligible prescription into the Express Scripts Automatic Refill program, the patient is given a standard 18-day buffer before the initial automatic refill. This allows enough processing and mailing time.  From that point on, the prescription will auto-refill exactly every 90 days.

The patient will receive a phone call/email 7 days prior to the refill to remind them of the next auto-refill.  They should have a ~25 day supply on-hand at time of notification and have the option to postpone the fill or let it be filled and sent.

Often, this can be perceived to the participant as receiving a refill “too soon” or “sooner than needed”. For this reason, the number of buffer days can be adjusted by the patient online or by calling Express Scripts customer service. The member may also discontinue the automatic refill at any time and go back to doing the refills themselves,  online or by phone.  If automatic refills are reinstated, the process will return to the initial 18-day buffer which may be seen as a delay. Keep this in mind as you are setting your automatic refills.

Medications excluded from the automatic refill program commonly fall under the following criteria:

  • All controlled substances or medications with legal restrictions or supply limitations
  • All specialty medications
  • Medications that are not indicated for chronic or maintenance use
  • Medications that often require frequent dose changes (e.g. chemotherapy medications)
  • Medications typically prescribed on an as needed basis (e.g. pain and migraine medications)
  • Medications where lack of specific dosing and use make it difficult to know when refills are needed (e.g. topicals)
  • Injectable medications (excluding diabetes medications)
  • Medications written with less than a 2 month supply


Medicare Part D – Annual Notification

As a participant of the A&M Care 65 Plus plan, you are enrolled in the Medicare Part D Prescription Drug Program. Each year, Medicare sends an annual notification of enrollment and a quick reference guide which provide valuable information about your Medicare coverage. Expect to receive this packet around the end of November . You do not need to take any action upon receipt of these materials, simply keep them for your records. If you have questions about your Medicare Part D plan, visit the A&M System Benefits website, and review the Retiree Benefits page or call Express Scripts Medicare at 1-855-895-4647.

Similar Posts