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Soaring Costs Prompt Change in Prescription Drug Program

​10/6/2016

The cost of prescription drugs continues to skyrocket. Every day, it seems, the media report a spike in the cost of yet another prescription drug.

On average, prescription drugs represent 20 to 25 percent of medical claims expenses nationally. The active Medical Plan of the Presbyterian Church (U.S.A.) is no exception; last year, it paid out $32 million for nearly 760,000 prescription drug claims, or 22 percent of its medical claims expenses. For 2016, the Board of Pensions projects that prescription drugs will again account for more than 20 percent of its claims expenses. And, these expenses have a direct impact on increased medical costs and dues.

In response, the Board entered into extended negotiations with its pharmacy benefits manager, OptumRx, to craft a contract for 2017-2019 that would blunt the impact of rising prescription drug costs while ensuring high-quality drugs would be available to plan members to save or improve their lives. The Board did so in the context of a changed prescription drug marketplace.

Exclusionary Formularies

For the past several years, major pharmacy benefits managers — and the plans they administer — have excluded certain drugs from their covered drug lists, or formularies, as a way to manage costs. Today, most faith-based organizations use exclusionary formularies.

The Board has long resisted adopting an exclusionary formulary, seeking as little disruption in members’ access to medications as possible. However, the Board has a fiduciary duty to be a faithful steward of the plan’s resources by diligently managing its costs. For the new contract with OptumRx, the Medical Plan faced a 20 percent price increase for its Prescription Drug Program if it did not incorporate an exclusionary formulary.

Prescription Drug Program Change Effective January 1, 2017

That’s why the Board of Pensions agreed, for the first time, to exclude certain drugs from coverage under the active Medical Plan* beginning January 1, 2017. Each excluded drug is a brand-name medication that medical and clinical experts agree does not offer a clear clinical advantage over other, less costly brand-name or generic drug alternatives. Plan members who fill prescriptions for excluded medications in 2017 will pay the full cost for these drugs.

Although this change to the 2017 Prescription Drug Program will not decrease prescription drug expenses, it is expected to slow the rapid rise in prescription drug costs and so help manage the overall cost of the Medical Plan.

What This Change Means to Members

Active plan members who are currently taking a medication that will be excluded from coverage in 2017 will receive a confidential letter from OptumRx in late October, identifying the drug and suggesting alternatives. If you receive a letter, the Board encourages you to share it with your physician and discuss whether any of the alternatives may be right for you. If you and your doctor determine that an alternative medication is appropriate for your condition, you will need a new prescription.

To view the 2017 OptumRx Formulary and the 2017 Prescription Drug Exclusion List, go to pensions.org.

If you have any questions, OptumRx representatives will be available after October 17, 2016, at 855-207-5868 to answer questions about specific medications.

*This change does not affect the Prescription Drug Program under the Medicare Supplement Plan; that prescription drug program is a Part D plan, governed by Medicare.