Outline intro to fmla (a1560721.doc;1)

Wheaton Franciscan Healthcare Associate Medical Plan – Pharmacy Benefit Enhancements for 2007 IMPORTANT INFORMATION FOR MEDICAL PLAN MEMBERS Because of some initial confusion over how out of pocket costs are determined for 90 day supplies of prescription medications in
2007, this communication clarifies the policy and gives an example of how the benefit is calculated.
A significant change was made to the medical plan design from 2006 to 2007, lowering out of pocket costs for plan members
when filling a 90 day supply of prescription medication at Wheaton Franciscan Healthcare Pharmacies. The change, which is
anticipated to save plan members over a half a million dollars in 2007, was communicated as a three month supply of
medication for two monthly co-payments.
To clarify, because the prescription drug benefit in our medical plan is based on a percentage cost share or “co-insurance”
(versus “co-payment” or flat dollar cost) with minimum and maximum out of pocket limits to keep extremely expensive drugs
affordable, the calculated plan member cost for a 90 day supply does not always equal twice the cost of a 30 day supply.
Constantly changing drug costs, compounded by different price points for different quantities purchased (i.e. 30 day versus 90
day supply) add to the complexity of determining out of pocket costs.
Here’s a summary of the change in out of pocket costs from 2006 to 2007 when filling a 90 day prescription utilizing a
Wheaton Franciscan Healthcare Pharmacy.

Drug Type

When 90 day prescriptions are filled, the appropriate co-insurance level is applied to the cost of the medication, and the final
cost to the plan member is determined when the minimum and maximum limits are considered. In the table above, notice that
the minimum and maximum limits for all drug types in 2007 have been reduced from the prior year, reflecting the change from
three to two co-payments. For example, the preferred drug cost maximum was $120 in 2006. In 2007 it is $80.
Here’s an example using the preferred brand drug Zyrtec used for allergies.

30 Day Supply
The current cost of a 30 day supply of Zyrtec is $70.00. Because it is a preferred brand, the plan member will pay 20% of the cost, with a minimum of $15 and a maximum of $40. 20% of the cost is $14.00. Because this is below the minimum, the minimum cost is applied. The plan member pays $15. The current cost of a 90 day supply of Zyrtec is $176.44. Because it is a preferred brand, the plan member will pay 20% of the cost, with a minimum of $30 and a maximum of $80. 20% of the cost is $35.29. Because this is between the minimum and maximum limits, the plan member pays $35.29. Note that in 2006 the plan member would have paid $45.00, not $35.29, as the calculated amount was below the minimum threshold. We hope that this communication provides a better understanding of how the cost sharing is calculated for a 90 day supply of prescription medication in 2007 that lowers your costs from the prior year. We apologize for any confusion. If you have any questions, please contact Healthcare Plan Director Pat Proft at 414-465-3448, or any of our Wheaton Franciscan Healthcare Pharmacies. Respectfully, Daniel Jambura Vice President - Benefits

Source: http://www.wfhplan.org/Uploads/2007%20Drug%20Co-Pay%20Coinsurance%20are%20Calculated.pdf