|
Prescription highlight reel
Everyone talks about the importance of prescriptions and their high cost. Some of your friends and family members have hit the “donut hole.” But not you! The city’s 5 health-plan choices provide seamless coverage over that gap. All 5 plans offer benefits much more generous than Medicare Part D.
You enjoy one of the richest prescription benefits around – fixed copayments for covered prescriptions. Those benefits are costly. We expect to spend more than $46 million in prescriptions in 2009. That’s more than 18 percent of the total health-plan cost. Half of that cost is for retiree prescriptions.
The chart below shows prescription-coverage costs for all 5 city health plans. Use this chart, the list of prescriptions on page 10, and the formulary list from each plan to determine which prescription benefits are best for you. Many of your fellow retirees say this is the most important factor when considering a new plan.
Prescription copayments at a
participating pharmacy |
|
Aetna |
TexanPlus |
Texas
Health-Spring |
HMO |
PPO |
|
31-day supply |
30-day supply |
Generic |
$10 |
$10 |
$10 |
$10 |
$10 |
Preferred brand |
$30 |
$30 |
$30 |
$30 |
$30 |
Non-preferred |
$45 |
$45 |
N/A |
$45 |
$45 |
Specialty drugs |
$45 |
$45 |
$45** |
$30/$45*** |
$30/$45*** |
90-day supply |
Generic |
$20 |
$20* |
$20 |
$20 |
$20 |
Preferred brand |
$60 |
$60* |
$60 |
$60 |
$60 |
Non-preferred |
$90 |
$90* |
N/A |
$90 |
$90 |
Specialty drugs |
$90 |
$90* |
$90** |
$30/$45*** |
$30/$45*** |
Special copayments |
Medicare Part B |
$0 |
20% up to $1,500 |
15% up to $1,000 |
Same as non-preferred brand |
*TexanPlus does not have a mail-order option. You can fill a 90-day prescription for a 2-month copayment at your local network pharmacy,
** Prior authorization is required.
*** Specialty-prescription drugs must be obtained through the Triessent Specialty Drug Program.
Top 10 retiree prescriptions by amount spent |
Drug
Treatment/Usual dosage (retail cost source) |
Copayment |
Retail cost
30-day supply |
Aetna |
TexanPlus |
Texas
HealthSpring |
HMOBTX |
1 |
Nexium GERD; 50 - 40 mg capsules; (Costco) |
$30** |
$30 |
$45 |
$30* |
$265 |
2 |
Lipitor Cholesterol; 30 - 20 mg tablets; (CVS) |
$30 |
$30 |
$30 |
$45* |
$135 |
3 |
Enbrel Rheumatoid Arthritis; (BCBSTX) |
$45 |
$45** |
$45** |
$30* |
$2,333 |
4 |
Actos Diabetes; 30 - 30 mg tablets; (CVS) |
$30 |
$30 |
$30 |
$30 |
$231 |
5 |
Diovan High Blood Pressure; 30 - 80 mg tablets; (CVS) |
$30 |
$30 |
$30 |
$30* |
$75 |
6 |
Prevacid GERD; 30 - 15 mg capsules; (CVS) |
$30** |
not covered |
$45 |
$45* |
$182 |
7 |
Lantus Insulin; (BCBSTX) |
$45 |
$30 |
$30 |
$30 |
$160 |
8 |
Humira Rheumatoid Arthritis; (BCBSTX) |
$30 |
$45** |
$45** |
$30* |
$2,312 |
9 |
Tracleer Primary Pulmonary hypertension; (BCBSTX) |
$45 |
$45** |
$45** |
$30* |
$4,480 |
10 |
Revlimid Biotech cancer treatment; (BCBSTX) |
$45 |
$45** |
$45** |
$30* |
$6,365 |
NOTES: Retail costs are listed on PharmacyChecker.com under Costco or CVS. Cost for drugs listed as BCBSTX are those paid by HMOBTX. Enbrel, Humira, Tracleer and Revlimid are specialty drugs; and under the BCBS HMO and PPO must be purchased through Triessent.
*Step-therapy drug.
**Requires prior authorization.
New rules in HMO & PPO plans
Two new step-therapy categories to help you win over high prices. As of May 1, two additional categories of medications are being added to step therapy. This gives you a chance to save money by requiring you to try generic versions of the medicine before moving on to more-expensive brand-name drugs. Remember, generics are copies of brand-name drugs, identical in dosage, safety, strength, quality, performance and intended use. And, they only cost you $10 for a 30-day supply at your local pharmacy, or $20 for a 90-day supply through Prime Therapeutics mail order.
Proton pump inhibitors for GERD, heartburn or stomach ulcers: If you take a proton pump inhibitor, such as Nexium, Prevacid or Protonix, your doctor must prescribe a generic PPI before you can receive a brand-name. This is the case even if you are currently taking a PPI. This will begin with the first refill you get after May 1. If the generic fails to sufficiently treat your condition, your doctor can request authorization to step you up to another generic or brand-name PPI.
Statins for high cholesterol: Members who begin taking a statin will be required to start with a generic statin. If the generic fails to sufficiently lower your cholesterol, your doctor can step you up to a preferred brand-name statin.
Members who currently take a brand-name statin, such as Lipitor or Vytorin, are grandfathered and may continue to take that medication. BCBSTX can change the tier in which any brand-name drug appears, increasing or decreasing your copayment. For a complete list of step-therapy drug categories, see page 11.
|
Triessent will now be your one-stop specialty drug pharmacy
If you take a high-cost specialty drug, such as Enbrel or Tracleer, you will soon receive a letter from Triessent asking that you call and sign up for the specialty-drug program. Once you have signed up, Triessent each month will send a 30-day supply of the specialty medication to your home or your doctor’s office. The 30-day supply will cost you just $30 or $45.
By sending you a 30-day supply, Triessent minimizes waste from discontinued therapy or dosage changes. A representative will call you to coordinate refills.
If you do not order your specialty drugs through Triessent, you will be able to get just one refill at your local retail pharmacy. After that, refill requests will be denied. Call 888-216-6710 to sign up for the program.
Specialty drugs are used to treat many different ailments, including cancer, cystic fibrosis, hemophilia, HIV, Hepatitis C, and multiple sclerosis. These drugs can cost thousands of dollars a month for a single prescription.
Triessent, a specialty pharmacy provider that manages specialty drug programs and services for the HMO and PPO, allows a more cost-effective purchase of these expensive medications. Go to www.bcbstx.com for a complete list.
 |
What is a formulary?
A formulary is a list of covered drugs. Each plan’s formulary is different and can change each year. The drug formulary established by Medicare for 2009 serves as the model for Medicare Advantage formularies. To find out which drugs are in each of the three tiers, visit these Web sites:
Formularies may change each January and May.
If the cost of the prescription is less than the copayment, you pay the lower amount.
|
|
