Vision plan improvements starting January 1, 2008
Beginning January 1, PEF’s PS&T members will see significant improvements to their vision plan benefit. These improvements were negotiated in the 2007-2011 PS&T contract.

You already have the first improvement – a 90-day purchase period for dress eyewear – that kicked in July 1. Previously, dress eyewear could only be purchased on the same date as the vision exam.

Now, the state has agreed to apply the 90-day purchase period to occupational eyeglasses, too, starting January 1, 2009.

Also starting January 1:
• The allowance for eyeglass frames is increasing from $100 to $130, which will expand your choice of “paid-in-full” frames.

• Standard polycarbonate and/or standard progressive (commonly referred to as no-line bifocal) lenses will be paid-in-full.

• The allowances for purchases from non-network providers will be slightly increased.

• Medical Exception Program annual vision exams (necessary because of a medical condition) will be covered, even if the new exam indicates your vision has not changed since the last exam.


New MHSA insurer named
 The state has picked United HealthCare/OptumHealth Behavioral Solutions (UHC/OptumHealth) to insure and administer mental health and substance abuse benefits for Empire Plan enrollees.

If the five-year contract is approved by the state comptroller, UHC/OptumHealth will replace GHI/ValueOptions in that role January 1.                                       simpkins@pef.org

The Communicator Home Page
Empire Plan Rx program changing
By LORRAINE SIMPKINS
Effective January 1, United Healthcare (UHC), the insurer for the Empire Plan Prescription Drug Program, will be permitted greater flexibility in administering the Empire Plan Preferred Drug List. It will be called the Empire Plan Flexible Formulary (EPFF).

The 2009 EPFF is designed to provide enrollees and the Empire Plan with the best value in prescription drug spending by:

• Placing generic and certain brand-name drugs on Level 1 (lowest copay) when clinically appropriate and financially advantageous to the Empire Plan;

• Excluding certain therapeutic categories of prescription drugs with two or more clinically sound and therapeutically equivalent Level 1 options from Level 2 (the mid-range copay level); and

• Excluding one or more drugs in select therapeutic categories from all levels if they have no clinical advantage over other less expensive covered drugs considered to be therapeutically equivalent.

EPFF drugs are grouped into therapeutic categories and also by the levels of required copayment.

Level 1 includes all generic drugs and some brand-name drugs. You pay $5 for up to a 30-day supply of a generic drug, whether you buy it at a retail pharmacy or by mail.

It also costs just $5 for a 31- to 90-days supply if you buy it by mail. However, that price doubles to $10 when you buy it from a retail pharmacy. Nevertheless, it’s cheaper than even a small amount of drugs from Levels 2 or 3.

Level 2 includes brand-name drugs selected for their overall health care value. They cost $15 for a supply of up 30 days; $20 for enough to last 31 to 90 days if ordered through the mail; and $30 for the 31- to 90-days supply from your retail pharmacy.

Level 3 drugs cost you and the Empire Plan the most. You pay $40 for enough to last up to 30 days. Your price goes to $65 when you order a larger supply (up to 90 days) through the mail. If you pick it up at your retail pharmacy, you pay $70.

UHC’s Pharmacy and Therapeutics Committee decides whether to cover drugs and at which level of copay based on their effectiveness, safety, market share, and cost compared with other drugs in the same therapeutic category.

Drugs considered to have no clinical advantage and which are not covered include those that:

• Contain an active ingredient available in and therapeutically equivalent to another drug covered in that therapeutic category;
• Contain an active ingredient which is a modified version of and therapeutically equivalent to a covered prescription drug; or
• Are available without a prescription or contain components available without a prescription.

Brand name drugs, with no generic equivalents, used to treat HIV/AIDS, cancer and anti-rejection drugs following an organ transplant are always covered and placed on the EPFF.

Whenever a prescription drug is excluded, generic and/or therapeutically equivalent brand-name drug alternatives will be covered. By excluding coverage of a small number of drugs, the EPFF discourages the use of more expensive "me-too", or copycat, medications that offer no significant health care advantage.

Drug exclusions and placement of medications on the EPFF can not be appealed. Benefits will not be provided for an excluded drug, regardless of why it is prescribed.

If you are taking an excluded medication or one that has moved from Level 2 to Level 3 talk with your doctor about prescribing a generic or Level 2 drug.

If you continue to use an excluded medication, you will be responsible for paying the total retail cost of it.

Consumer Reports Best Buy Drugs provides free, easy-to-understand information on drug safety, effectiveness and cost based on the best available scientific evidence.

More information about the EPFF is posted online under Health Benefits at www.pef.org.