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Pharmacy Benefit Manager Transition Information

Transition Complete

The WTC Health Program has completed this transition to Express Scripts, the Pharmacy Benefit Manager, as of June 1, 2022. For the latest on Program pharmacy benefits, visit the Pharmacy Benefits page.

Starting June 1, 2022, Express Scripts will replace Managed Care Advisors and Optum as the World Trade Center (WTC) Health Program Pharmacy Benefit Manager (PBM). The WTC Health Program is working with both vendors to ensure a smooth transition for our members. Members with a certified condition should be on the lookout for mail from the WTC Health Program or Express Scripts about this change.

You can also learn more about this change and the new vendor in the FAQs below and on the Express Scripts website .

This page will be updated as more information about the PBM transition becomes available.

The WTC Health Program mailed notification letters to members with a certified condition. Letters are available in English, Español, Polski, and 中文:

Key Information

  • June 1, 2022 Express Scripts will replace Managed Care Advisors and Optum as the WTC Health Program Pharmacy Benefit Manager (PBM).
  • In May, 2022, members with a certified condition will receive a welcome kit from Express Scripts. This kit will include your new WTC Health Program Prescription ID card.
  • Most members are expected to be able to stay with their current pharmacies. If you will need to change pharmacies, Express Scripts will send you a letter with the steps you can take. Your home delivery and specialty pharmacy network may be changing as well, Express Scripts will send you a letter if this affects you.

PBM Transition FAQs

What is a Pharmacy Benefits Manager (PBM)?

A PBM is a company that is contracted to administer drug benefit programs. The PBM provides all pharmacy services for the WTC Health Program to ensure members can get coverage for prescription drugs used to treat their WTC-related condition(s). These services include a call center and customer service for pharmacy benefits, managing the Program’s pharmacy formulary, home delivery and specialty pharmacy services, and processing of prescription drug claims.

Why is the Pharmacy Benefits Manager (PBM) changing?

The WTC Health Program contracts with external organizations to provide essential Program services, such as pharmacy benefits. When a contract is up for renewal, other companies can bid to provide those services. The PBM contract was awarded to Express Scripts after a robust evaluation of competing proposals.

When will Express Scripts take over as the Pharmacy Benefits Manager (PBM)?

Express Scripts will become the new Pharmacy Benefits Manager (PBM) on June 1, 2022. Until then, Optum will continue to operate as your PBM. Please continue to use your pharmacy benefits as you have been and contact Optum for any current pharmacy needs or questions at 1-855-640-0005 until May 31, 2022. Starting June 1, 2022, you will contact Express Scripts for any pharmacy needs.

Is there anything I need to do?

Not at this time. In May, if you are eligible for prescription coverage, you will receive a Welcome Kit from Express Scripts in the mail that includes your new WTC Health Program Prescription ID card and information about specialty medications and home delivery options.

You may receive other letters depending on your situation, so be on the lookout for any mail from Express Scripts. Please continue to call Optum at 1-855-640-0005 for any pharmacy-related questions or support needs through May 31, 2022. Starting June 1, 2022, you will contact Express Scripts.

What is a transition period?

A transition period is the time between when the new vendor is awarded the contract and when they take over full operations. During this time, prescription fills continue as usual until the new vendor (Express Scripts) is ready to assume all Pharmacy Benefit Manager (PBM) duties. This process is in place to work towards a smooth change of vendors.

Will I need to change my pharmacy?

We expect many members will be able to continue filling WTC-related prescription(s) at their current pharmacies. Express Scripts has a retail pharmacy network that includes approximately 62,000 pharmacies and 98% of recent retail claims were made at these pharmacies. If you need to change pharmacies, Express Scripts will notify you directly.

How much medication will I be able to get with my prescription with Express Scripts?

For Responders: You will be able to get up to a 90-day supply of WTC-related long-term medication(s) at Walgreens/Duane Reade retail pharmacies and through home-delivery. You can get up to a 30-day supply of long-term medications at other in-network retail pharmacies. Express Scripts will include this information in a Welcome Kit that will be sent in May.

For Survivors: This may depend on your primary insurance requirements. You can get up to a a 90-day supply of WTC-related long-term medication(s) at any in-network retail pharmacy. Express Scripts will include this information in a Welcome Kit that will be sent in May.

How will Coordination of Benefits requirements work with the new PBM? (Survivors Only)

To process WTC-related prescriptions the pharmacy must bill your primary insurance first, including any public insurance such as Medicare or Medicaid, and then bill the Program the remaining amount. This leaves no out-of-pocket cost to you. This process is called Coordination of Benefits and is a requirement for Survivors according to the James Zadroga 9/11 Health and Compensation Act of 2010.

If your insurance status has changed recently, please make sure to update your primary insurance information with your Clinical Center of Excellence or the Nationwide Provider Network. Starting June 1, 2022, outdated or inaccurate insurance information could impact the ability of the pharmacy to process your WTC-related prescriptions.

Will I be able to use home delivery for my WTC-related medication(s) with Express Scripts?

For Responders: Yes, Responders have the option to get their WTC-related medications delivered through Express Scripts. If you already get your WTC-related medications delivered through OptumRx, these prescriptions and your delivery information will automatically transfer to Express Scripts June 1, 2022. You can get up to a 90-day supply of your WTC-related long-term medication through Express Scripts Home Delivery Pharmacy.

For Survivors: That depends on what home delivery pharmacies are in your primary insurance’s network. Express Scripts Home Delivery Pharmacy is not able to process Coordination of Benefits with out-of-network home delivery pharmacies.

If you have Express Scripts as your primary insurance, you will be able to use their home delivery pharmacy to get your WTC-related medications at no cost.

Express Scripts network includes CVS/Caremark and Optum home delivery pharmacies for Survivors as well. If CVS/Caremark and Optum home delivery pharmacies are in network for your primary insurance you can have your WTC-related prescriptions delivered through them.

If you have any other primary coverage than mentioned above, please call Express Scripts to discuss what home delivery options are available.

Also, if you already get your WTC-related medications delivered through OptumRx, and Optum is your primary insurance, you will continue to receive your WTC-related medication(s) as usual.

What if I have specialty medications?

Some WTC-related conditions are complex and/or chronic and require specialty medication. Specialty medication often require special handling (such as refrigeration during shipping) and administration (such as infusions).

For Responders: When Express Scripts becomes the new Pharmacy Benefits Manager (PBM) on June 1, 2022, all specialty medication prescriptions for your certified WTC-related condition(s) will need to be filled through Accredo Specialty Pharmacy, an Express Scripts specialty pharmacy.

If you are currently filling WTC-related specialty medications through Optum Specialty Pharmacy, Express Scripts will automatically transfer your prescriptions to Accredo Specialty Pharmacy on June 1, 2022. Express Scripts will send out a letter before this happens with more details.

If you are currently filling WTC-related specialty medications through retail pharmacies, you will need to transfer your prescriptions to Accredo by September 1, 2022. Express Scripts will reach out directly to you with more information about how and when to move your prescriptions over.

For Survivors: When Express Scripts becomes the new Pharmacy Benefits Manager (PBM) on June 1, 2022, you have the option to fill specialty medications at Accredo Specialty Pharmacy, or any in-network retail or other participating specialty pharmacy.

If you are currently filling WTC-related specialty medications through Optum Specialty Pharmacy, Express Scripts will automatically transfer your prescriptions to Accredo Specialty Pharmacy on June 1, 2022.

I heard the Nationwide Provider Network (NPN) is also transitioning to a new vendor, is that the same as the Pharmacy Benefit Manager (PBM) Transition?

The PBM change is separate from the NPN vendor change. Members in the NPN should visit the NPN Transition webpage to learn more about the WTC Health Program NPN transition.

What if I have questions?

For pharmacy benefits or home delivery questions, please continue to call Optum at 1-855-640-0005 until further notice.

For questions about the Pharmacy Benefits Manager (PBM), the transition, or general questions about the Program, please contact the WTC Health Program call center at 1-888-982-4748.

For questions about your prescription medications or WTC-related care, please contact your clinic.

The World Trade Center Health Program has also sent some letters to members with important information: