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Prescription plan highlights
You’ve managed this game so well, we can maintain the prescription benefit with only a couple of program notes. And for the most part, prescription benefits will stay the same. We’ve added two new step-therapy drug categories and the Triessent Specialty Drug Program.
This is a three-tier prescription plan, with different copayments in each tier. Drugs are assigned to the tiers based on the BCBSTX formulary, which can change annually, usually in May.
Prescription copayments |
|
Retail pharmacy
(30-day supply) |
Mail-order pharmacy
(90-day supply) |
Generic |
$10 |
$20 |
Preferred brand |
$30 |
$60 |
Non-preferred brand |
$45 |
$90 |
Reviewing the rules of the prescription game
Mandatory generic
The mandatory generic feature calls for filling your prescription with a generic drug if one is available. Remember, generic drugs are copies of brand-name drugs, identical in dosage, safety, strength, quality, performance and intended use. If you still prefer the brand-name drug when a generic is available, you will pay extra.
How mandatory generic works |
If your doctor prescribes a generic drug but you purchase a brand prescription, you will pay more for your medicine. Your copayment will be the total of the generic copayment, plus the difference between the cost of the brand and the generic drug. |
Doctor prescribes generic Zolpidem Tartrate |
$17.30 |
You purchase brand-name Ambien |
$226.88 |
Difference in price |
$209.58 |
Your cost = price difference + $10 generic copayment |
$219.58 |
Mail order
Through BCBSTX’s mail-order pharmacy, Prime Therapeutics, you can order a 90-day supply for the price of a 60-day supply.
To switch your maintenance prescriptions to Prime Therapeutics and save 33 percent, get a mail-order form from your human resources liaison.
Step therapy
To save you and the city money, the plans require your doctor to try a generic prescription before prescribing a higher-priced brand drug. If the alternative drug fails to alleviate your condition, your doctor can request authorization to step you up to the more-costly prescription.
The step-therapy feature saves you money by requiring your doctor to consider alternative medications before prescribing higher-cost medications in seven categories:
- New! Proton pump inhibitors for GERD, heartburn and stomach ulcers (Nexium, Prevacid, Protonix)*
- New! Statins for high cholesterol (Lipitor, Vytorin, Zocor)*
- COX-2 inhibitors for inflammation/pain (Celebrex)
- Leukotrienes for asthma (Accolate, Singulair)
- Rheumatoid arthritis drugs (Enbrel, Humira, Kineret)
- ACE inhibitors for high blood pressure/congestive heart failure (Accupril, Mavik, Altace, Aceon)
- Angiotensin II receptor blockers for high blood pressure(Avapro, Atacand, Cozaar, Diovan)
New drugs may be added periodically.
Quantity versus time
Certain drugs are limited to a specific quantity over 30 or 90 days. This is called quantity versus time and applies to retail and mail-order prescriptions, including nasal and asthma inhalers, migraine medications, pain-management medicines, proton pump inhibitors, and others. When more medication is necessary, BCBSTX must approve the higher quantity. To find out what drugs are subject to quantity limits, visit www.bcbstx.com or call 800-521-2227.
Triessent Specialty Drug Program
High-cost specialty drugs, such as Enbrel or Tracleer, are now available exclusively through the Triessent Specialty Drug Program. Once you have signed up, Triessent will send a 30-day supply of the specialty medication to your home, your designated address or your doctor’s office each month. The 30-day supply will cost you just $30 or $45.
Top 10 prescriptions by amount spent |
Drug Treatment/Usual dosage |
Copayment |
Retail cost 30-day supply** |
1 |
Nexium* GERD; 40 mg capsules; (Costco) |
$30 |
$265 |
2 |
Lipitor* Cholesterol; 20 mg tablets; (CVS) |
$45 |
$135 |
3 |
Enbrel* Rheumatoid Arthritis; (BCBSTX) |
$30 |
$2,333 |
4 |
Actos Diabetes; 30 mg tablets; (CVS) |
$30 |
$231 |
5 |
Prevacid* GERD; 15 mg capsules; (CVS) |
$45 |
$182 |
6 |
Diovan* High Blood Pressure; 80 mg tablets; (CVS) |
$30 |
$75 |
7 |
Valtrex Herpes Virus; 1000 mg caplets; (CVS) |
$30 |
$382 |
8 |
Lantus Insulin; (BCBSTX) |
$30 |
$160 |
9 |
Humira* Rheumatoid Arthritis; (BCBSTX) |
$30 |
$2,312 |
10 |
Topamax Seizures/Convulsions; 50 mg tablets; (CVS) |
$30 |
$290 |
NOTE: top 10 list is for all plans and all members. *Step-therapy drug. **Retail costs as of 10/31/2008 are listed on PharmacyChecker.com under Costco or CVS. Cost for drugs listed as BCBSTX are those paid by HMOBTX
If you currently have a mail-order prescription for a brand-name proton pump inhibitor with Prime Therapeutics, you must ask your doctor for a new prescription. Otherwise, you will be charged for the full cost of the prescription plus the cost of the generic minus the generic copayment of $10.
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