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City staff say Express Scripts error briefly made 90-day pharmacy fills mandatory; refunds issued
Summary
City benefits staff said a citywide Smart 90 prescription option — intended as voluntary — was mistakenly implemented as mandatory by vendor Express Scripts, triggering penalties for some members; staff said they corrected the setup, overrode assessed penalties and began refunds, with the voluntary 90‑day option active June 1.
Kristen, a city benefits staff member, told the committee that Express Scripts offers a program allowing city employees and retirees to obtain 90‑day prescriptions at retail pharmacies as an alternative to the mail‑order option.
She said the option was intended to be voluntary but that an implementation error on the vendor's side set the program up as mandatory. "We didn't realize this until the end of April," Kristen said, and "we overrode the penalty," adding that affected members who paid charges would be reimbursed.
Kristen described the program's structure and why it can save members and the city money: "Basically, what you're getting for 90 days is you're basically paying for 2 co pays instead of 3 co pays," she said, and estimated that a member taking a non‑brand drug could save about $140 a year by switching to 90‑day fills.
She explained how copays are calculated under the plan and why amounts vary for generic drugs: the member pays the lowest market price on the day of fill up to the stated copay cap. "For our contract, it cannot go over the 5," Kristen said, describing that the plan caps out‑of‑pocket cost at $5 for eligible generics in the relevant tiers.
On the timing of the fix, Kristen said the city and Express Scripts worked to correct the setup and that the voluntary option was implemented June 1; she said the city has been processing refunds and overriding penalties for members who were charged during the erroneous mandatory setup. "If by chance someone picked up the prescription and they had paid the penalty, they could bring it to us, and we were in the process of processing those refunds so that they are getting they're being made whole," she said.
Kristen also described the city's outreach: Express Scripts sent letters and emails where possible, the city emailed employees with city accounts and coordinated with union 466 for members without city email addresses, and individualized follow‑ups were used for affected members. She acknowledged the city did not perform a separate mass mailing because it relied on Express Scripts' communications but said she had approved the initial communication and that consultants reviewed the material.
The benefits staff framed the change as a net improvement for members who want less frequent pharmacy visits and potential savings: "It is really it's a benefit to our employees, our retirees," Kristen said. She also offered to explore better communication channels for retirees who lack city email addresses.
The committee did not take formal action on the program during the meeting; staff said the item will appear on the council agenda for Monday, where directors may be available to answer further questions.
