Who will be Medica’s new pharmacy benefit manager (PBM) in 2020?

Express Scripts®

What is the timeline for this change?

Express Scripts will become the PBM for all Medica members starting January 1, 2020.

Why is Medica changing its PBM?

To enhance quality outcomes for members while achieving greater cost efficiencies.

How do pharmacies get in the network?

The pharmacy can contact the Express Scripts Pharmacy Help Desk at 1-800-922-1557 (toll free) to request participation in the network.

Will there be new drug lists for Medica as a result of the new PBM?

Yes. Starting January 1, 2020, Medica’s List of Covered Drugs (formulary) will change as a result of the new PBM. Some members will see changes in their prescription coverage for certain drugs and supplies. These members will receive a letter in the mail explaining the drug list change and include covered alternative options.

Will there be changes in how the drug lists are maintained?

Medica will continue to update drug lists on medica.com on a monthly basis. Until they are reviewed and approved for drug formularies, new drugs will be either pended (won’t adjudicate until reviewed) or placed on tier 3 (non-preferred for retail; specialty tier 2 non-preferred for specialty products).

Will Medica be sending letters to members indicating if they need to change medications?

There will be a new List of Covered Drugs (formulary) for all members on January 1, 2020. Medica will begin mailing impacted members coverage change notifications in October 2019, and will continue through the end of the year.

What are the BIN/PCN/RX Group numbers for Medica members?

There is one BIN (003858) for all Medica members. However, the PCN and RX Group numbers vary by membership.

 

 

How do I initiate prior authorizations or appeals for Medica members?

You can find everything you need to make a request on your patient’s behalf starting January 1, 2020, at medica.com/rxpa.

If a member has a prior authorization on file with CVS Caremark, does it need to be re-authorized with Express Scripts?

Medica will be working with CVS Caremark to transfer eligible prior authorizations to Express Scripts. Medica will honor existing prior authorizations through their end date if they are for drugs on Medica’s List of Covered Drugs (formulary).

For drugs that will no longer be on Medica’s List of Covered Drugs (formulary), prescribers can switch their patient to a covered drug, or request a formulary exception from Express Scripts starting January 1, 2020, at medica.com/rxpa.

What do I do if I have a patient who needs to start a new drug that will require prior authorization?

Providers will need to request prior authorization through Express Scripts starting January 1, 2020, at medica.com/rxpa.