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Medicare - Pharmacy Program |
Pharmacy Benefit Design
The Plan offers several pharmacy benefit designs which determine coverage of certain drugs as well as copayment amounts. Each pharmacy benefit plan is subject to pharmacy benefit regulations, state and federal laws, clinical guidelines, as well as the prior authorization process (described further on in this section) and quantity limitations, unless otherwise specified.
Members must pay a copayment or coinsurance, as determined by their benefits, for each supply of medicine received at a Plan participating pharmacy or through an affiliated mail order pharmacy. Depending on a member’s pharmacy plan specifics, a 90-day supply mail order prescription drug service may be available. Please read the Mail-Order Pharmacy Program section for more information. Prior approval and/or quantity limits apply to certain medications.
Tier Cost-Share Structure:
• Tier 1 copay: generic drugs.
• Tier 2 copay: preferred brand drugs.
• Tier 3 copay: non-preferred brand drugs.
• Tier 4 coinsurance: specialty drugs.
Generic versus Brand Medicines
The Plan’s prescription benefit design is formatted into four categories of prescription medications, as defined below. All covered medications fall into one of the described categories. The Pharmacy and Therapeutics Committee is responsible for managing and updating in which category a drug is placed. Due to the number of drugs on the market and the continuous introduction of new drugs, new applications of existing drugs and new information regarding safety, the design is dynamic and continually being revised.
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Tier 1 copay: Generic Drugs
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Generic drugs (Tier 1) offer an excellent value to the consumer. They are
chemically identical to brand drugs, but are priced at a fraction of the cost of
the corresponding brand drug. To gain FDA approval, a generic drug must:
• Contain the same active ingredients as the branded drug (inactive ingredients may vary).
• Be identical to the brand drug in strength, dosage form, safety, and route of administration.
• Be of the same quality, performance characteristics, and use indications.
• Be manufactured under the same strict standards of the FDA’s good manufacturing practice regulations required for branded products.
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Tier 2 copay: Preferred Brand Drugs
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The Plan has identified a listing of preferred brand drugs (Tier 2) available
at a lower copay than drugs in the non-preferred brand drug category (Tier 3).
Members get the medication they need while saving
money.
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Tier 3 copay: Non-Preferred Brand Drugs
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If a drug in the non-preferred drug category (Tier 3) is prescribed, it is
likely that there is a similar drug available in the formulary generic drug
category (Tier 1), or formulary brand category (Tier 2), which would be more cost-effective than choosing the non-formulary brand drug (Tier 3).
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Tier 4 coinsurance: Specialty Drugs
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These drugs consist of certain biotechnology self-injectable, infusion, and
advanced oral medications. These medications often require special handling, a
higher level of pharmacy expertise, and increased patient knowledge to
administer. In most cases, these medications are not needed immediately for
acute conditions, and traditionally are not stocked by retail
pharmacies.
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