SCRIPT | Pharmacy Update

Dedicated portal provides streamlined access to resources and information 

Earlier this month, we announced the launch of the new Pharmacy Portal.

If you have not registered for access yet, you can do so by emailing the Pharmacy Help Desk at script@independenthealth.com. Please include your NPI number in the request.

Our team will verify your request and provide instructions that can be shared among your staff as you see best. You will receive new credentials, replacing the login information you may currently have saved for the existing Provider Portal.

Once you receive the new credentials, access the new Pharmacy Portal at pbdrx.com/pharmacy.

All of the information and documents previously stored in our secure Provider Portal are now found on the new Pharmacy Portal, including:

• MAC pricing and appeals
• Payer sheets
• Important policies and forms, including the Pharmacy Manual
• E-newsletters from both Independent Health and Pharmacy Benefit Dimensions
• Timely updates critical to your operations

Thank you for your continued partnership. We look forward to your feedback as we continue to enhance the content available on the portal. 

Weight Loss Medication Policy for Commercial Members

Requirements for the approval of GLP-1s indicated for weight loss

As the use of glucagon-like peptide-1 (GLP-1) receptor agonists for weight loss continues to grow, we know our pharmacy partners are having conversations with their patients about these drugs. We thought it would be helpful to have some familiarity with our Weight Loss Medication policy as it applies to many of our commercial plan members. *

Currently, the GLP-1s approved for the treatment of weight loss covered on our commercial formularies with prior authorization are:

• Saxenda (liraglutide)
• Wegovy (semaglutide)
• Zepbound (tirzepatide)

Experts agree that safer, more cost-effective strategies proven to achieve and maintain a healthy weight should be tried well before medication therapy.

Therefore, prior authorization criteria for GLP-1s and other prescription weight loss medications require an in-person assessment and documentation of active participation in an evidence-based, lifestyle management program before coverage is considered.

Prescribers must also attest that the risks, benefits, alternatives, and possible complications of treatment with a GLP-1 for weight loss have been discussed with their patient and documentation of the discussion is in the patient’s medical record.

Working together, we can all support a member's safe journey to better health and better outcomes, and help promote long-lasting lifestyle changes.

* Benefits will vary by plan. 

Summary of the most significant changes impacting pharmacies

New: Medicare Prescription Payment Plan for Part D covered drugs
Starting in January, Medicare members will have the option to pay $0 at point of sale for their Part D covered drug(s) by enrolling in a payment plan. The new program is anticipated to roll out as follows:

• The pharmacy will be PAID IN FULL by the plan.
• The plan will bill a monthly invoice to the member.
• For members who enroll in the plan, two transactions will happen at the pharmacy:
  1. Pharmacy submits the initial Part D claim.
  2. After this submission, the pharmacy receives a response from the plan which will include instructions for submitting the second transaction.
• All Part D claims that cost the member $600 or more out of pocket will require the pharmacy to provide a “likely to benefit” notification in most cases at the point of sale.
  • Exceptions include members who have already opted in to the Medicare Prescription Payment Plan, ITU Pharmacies, or claims in the month of December.
• The pharmacy will be provided a model template from CMS to give to Medicare members for these claims and will be notified with a new NCPDP code.

Part D Redesign: No more donut hole
The Medicare Part D plan structure is changing for 2025. There is NO MORE donut hole for Medicare members. Members will go through only three phases of coverage:

• Deductible Phase: member pays 100% of the cost-share up to the deductible amount.
• Initial Phase: member pays the cost-share associated with the drug coverage tier up until the $2,000 out of pocket max is reached.
• Catastrophic Coverage Phase: all drug costs are $0 for the member for the remainder of the plan year.

As we learn more about these changes and further enhance our processes to manage the changes, we will continue to communicate with our pharmacy partners. Thank you for your continued hard work to care for our members. 

Initiatives to increase access to diabetes and maternity care

Beginning January 1, the following changes will be in place in the state of New York:

• Reduction of copays to $0 for most Commercial and Essential Plan members to increase access to insulin
• Reduction of diabetic treatment copays to $0 for some Commercial and Essential plan members to increase access to diabetic care
• Elimination of cost-shares for most services for some Commercial and Essential members during pregnancy and postpartum to expand prenatal and pregnancy care

We will continue to watch for and communicate changes at the state level for the upcoming year.

Formulary changes for the Third Quarter of 2024 are summarized here.

Access all of Independent Health's drug formularies.

If you have any questions regarding information in this issue, please call our Pharmacy Help Desk at (716) 631-2927 or 1-800-993-9898, Monday through Sunday from 7 a.m. to 11 p.m.

Thank you for your continued care of our community.