PHARMACIST STEVE

this is the website provided by Medicare.gov  https://www.medicare.gov/plan-compare/#/?year=2024&lang=en

I found that this website  and the content regarding comparing various Part D prgms that are being offered are lacking some information about what is covered, math is incorrect.  Seems like whoever put these info pages together, either didn’t know what they were doing or intentionally putting out incomplete or confusing information. Remember, part D prgms are all being provided by FOR PROFIT INSURANCE COMPANIES.

From Silver Scripts Evidence of Coverage – basically the 99 page the Part D “policy”.

New prescriptions the pharmacy receives directly from your doctor’s office. The pharmacy will automatically fill and deliver new prescriptions it receives from health care providers, without checking with you first, if either:· You used mail-order services with this plan in the past, or · You sign up for automatic delivery of all new prescriptions received directly from health care providers. You may request automatic delivery of all new prescriptions at any time by continuing to have your doctor send us your prescriptions. No special request is needed. Or you may contact Customer Care to restart automatic deliveries if you previously stopped automatic deliveries.If you receive a prescription automatically by mail that you do not want, and you were not contacted to see if you wanted it before it shipped, you may be eligible for a refund.If you used mail-order in the past and do not want the pharmacy to automatically fill and ship each new prescription, please contact Customer Care. If you have never used our mail-order delivery and/or decide to stop automatic fills of new prescriptions, the pharmacy will contact you each time it gets a new prescription from a health care provider to see if you want the medication filled and shipped immediately. It is important that you respond each time you are contacted by the pharmacy, to let them know whether to ship, delay, or cancel the new prescription. Refills on mail-order prescriptions. For refills of your drugs, you have the option to sign up for an automatic refill program. Under this program we will start to process your next refill automatically when our records show you should be close to running out of your drug. The pharmacy will contact you prior to shipping each refill to make sure you are in need of more medication, and you can cancel scheduled refills if you have enough of your medication or if your medication has changed.If you choose not to use our auto-refill program but still want the mail-order pharmacy to send you your prescription, please contact your pharmacy 15 days before your current prescription will run out. This will ensure your order is shipped to you in time. To opt out of our program that automatically prepares mail-order refills, please log on to your Caremark.com account or contact us by calling Customer Care.

The vast majority of electronic Rxs, sent by prescribers goes thru a “switch”, which is basically a electronic routing of any/all communications between pharmacies and prescribers. Now there is only ONE SWITCH since Sure Scripts & Rxhub merged with Rxhub being the “survivor ” of the merger and Rxhub is owned by CVS Health/Caremark and Express Script PBMs and those two PBMs, manage > 50% of all Rxs filled in pharmacies.

In the RED TEXT above from Silver Scripts, to me, suggests that Caremark may just divert any e-RX from a prescriber to your pharmacy of choice and send it to their mail-order pharmacy and they will contact pt if they want the mail order pharmacy to fill the new Rx. And apparently your only options once they contact you – let them know whether to ship, delay, or cancel the new prescription – if you don’t want them to fill it, you will need to contact your prescriber to send another E-Rx and hope that Caremark doesn’t snag it again.

I went to Caremark’s website looking for the place where I could opt-out of mail-order. Could not find anywhere to do it. So, I called their Customer Care and talk to their representative ( Lucy) who said that there was no OPT-OUT. If  your prescriber designated your pharmacy of choice, your Rx will be sent to that Pharmacy.

Now choosing a Part D plan that is accepted by your pharmacy of choice.  Normally with health insurance, there are providers in-network and out-of-network, but in the Medicare.gov site, Silver Scripts only show if a pharmacy in-network or out-of network, but when you get Silver Scripts pharmacy network guide – you find out that they have  in-network and IN-NETWORK  (preferred) pharmacies. The “preferred” pharmacies – you get lower co-pays than just in-network pharmacies. In the county where we live, the only “preferred” pharmacies are CVS, and big box or grocery store pharmacies.  Missing from the “preferred group” is CVS’ largest community competitor – WALGREEN – that has more stores in my county than CVS!

If you use CVS mail order pharmacy – they promise – Usually, a mail-order pharmacy order will be delivered to you in no more than 10 days.

Now you go to their drug formulary. Notice under column Tier Requirements/Limits, the vast majority of meds -especially generics have the limits of MO – and MO stands for MAIL ORDER.  On the Medicare.gov website, Silver Scripts didn’t mention REQUIRED MAIL ORDER. Back to my conversation with Customer Care Representative (Lucy), when I questioned mandatory mail order – according to Lucy – NOPE.

Back to the first section copied above from their 99 page policy explanation and in RED TEXT.. that if you never use their mail order it would appear that they are going to snag new e-Rxs and contact you if you want their mail order to fill it.  If you routinely, tell them to delete the new order, will the time frame from when they get the next new e-Rx and they contact you.. get LONGER & LONGER ?

Here is a page out of Silver Scripts formulary

Drug Name       Drug            Tier Requirements/Limits

NSAIDS
celecoxib capsule 400mg 4 QL (30 EA per 30 days) MO
celecoxib capsule 100mg, 200mg, 50mg 4 QL (60 EA per 30 days) MO
diclofenac potassium tablet 50mg 2 QL (120 EA per 30 days) MO
diclofenac sodium dr 2 MO
diclofenac sodium er 2 QL (60 EA per 30 days) MO
diclofenac sodium/misoprostol tablet delayed release 50mg; 200mcg 4 QL (120 EA per 30 days) MO
diclofenac sodium/misoprostol tablet delayed release 75mg; 200mcg 4 QL (90 EA per 30 days) MO
diflunisal 2 QL (90 EA per 30 days) MO
ec-naproxen tablet delayed release 375mg 2 QL (120 EA per 30 days)
ec-naproxen tablet delayed release 500mg 2 QL (90 EA per 30 days) MO
etodolac er tablet extended release 24 hour 600mg 4 QL (30 EA per 30 days) MO
etodolac er tablet extended release 24 hour 400mg, 500mg 4 QL (60 EA per 30 days) MO
etodolac capsule 300mg 2 QL (120 EA per 30 days) MO
etodolac capsule 200mg 2 QL (90 EA per 30 days) MO
etodolac tablet 500mg 2 QL (60 EA per 30 days) MO
etodolac tablet 400mg 2 QL (90 EA per 30 days) MO
FENOPROFEN CALCIUM CAPSULE 400MG 4 QL (240 EA per 30 days) MO
fenoprofen calcium tablet 600mg 4 QL (150 EA per 30 days) MO
flurbiprofen tablet 100mg 2 QL (90 EA per 30 days) MO
ibu 1 MO
ibuprofen tablet 400mg, 600mg, 800mg 1 MO
ibuprofen suspension 2 MO
ketoprofen extended release capsule 200mg 4 QL (30 EA per 30 days) MO
ketorolac tromethamine tablet 10mg 2 QL (20 EA per 30 days) PA MO
meloxicam tablet 1 MO
nabumetone 2 MO
naproxen sodium tablet 275mg, 550mg 2 MO
naproxen tablet 250mg, 375mg, 500mg 1 MO
naproxen suspension 4 MO
naproxen tablet delayed release 375mg 2 QL (120 EA per 30 days) MO
naproxen tablet delayed release 500mg 2 QL (90 EA per 30 days) MO
oxaprozin 2 QL (90 EA per 30 days) MO
piroxicam capsule 20mg 2 QL (30 EA per 30 days) MO

What is a pt to do?

what I may end up doing is to use the discounted cash price that the independent pharmacy that we patronize offers.  If we stayed with the Humana Part D that we have had for the last 3-4 yrs, as opposed to signing up with Silver Scripts.  The difference between premiums and annual deductible would be abt $2100 for a year. Both Part-Ds are not paying for two meds each of us take. By, paying cash, we don’t have to deal with prior authorizations, daily dose limits, step therapy, and other PBM’s BS.  Our prescriber will not have to deal with getting prior authorizations on your meds.  Our pharmacy will not have to pay the PBM a charge per Rx submitted electronically and they will not get any claw back in DIR fees ( direct and indirect remuneration fees).  https://www.pharmacytimes.com/view/white-paper-dir-fees-simply-explained.  The first week of Jan, 2024, I am going to request a refill on what should be a fairly inexpensive med, that one of us takes, to see if Silver Scripts rejects payment because mail order is mandatory.

Filed under: General Problems