Prescription Drugs

	Prescription plan features
	Prescription coverage
	Example of generic drug savings
	Top 20 prescriptions for employees and retirees

Through your careful use of prescriptions, release of new generic drugs, and plan changes, drug spending in the city’s HMO and PPO has flattened. Your use of generic alternatives and other cost conscientious choices have really paid off, so the prescription benefits will stay the same for this plan year.

But that doesn’t mean you can stop here. The gameboard changes constantly, with prescription drug costs continuing to increase at a faster rate than other medical costs, introduction of new high-priced drugs, brand name patents expiring resulting in new generics, and unusual new uses for those pricey brand name drugs.

You’ve become better consumers of prescriptions – probably because you are asking the right questions:

• Is this medication required for my condition, or will it get better by itself?
• Is this the best medication for my condition?
• Is there a generic medication available?
• If I have to take medication for more than 30 days, is mail order less expensive?
• Will this medication interact badly with other medications I take?

The drug manufacturers want you to be charmed by their colorful advertisements, and ask your doctor for the newest high-cost drug. Of course! That’s the one that makes the most money for them. Don’t be charmed – Be smart! Ask these questions, and you can do your part to slow unnecessary drug cost increases. If your doctor prescribes medication, make sure you discuss it, and understand how it is supposed to work.

Prescription plan features

Here are the features of your prescription benefit that are keeping the plan affordable:

1. This is a 3-tier prescription plan, with different copayments in each tier. See the chart of prescription coverage.

Drugs are assigned to the 3 tiers, according to the BCBS formulary, which can change annually. Tier 1 contains generic drugs. Tier 2 contains “preferred” brand name drugs. Tier 3 contains other covered brand name drugs. Tier 2 drugs are always less expensive than Tier 3 drugs. Drugs can change among tiers, usually in May.

2. The mandatory generic feature calls for filling your prescription with a generic drug, if one is available and if your doctor allows it. If you prefer the brand name drug to a generic, you will pay extra for the brand name drug.

		Mandatory generic 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 Fluoxetine $24.99 You purchase brand-name Prozac $147.99 Difference in price $123 Your cost = price difference + $10 generic copayment $133

3. The step therapy feature applies to 5 classes of prescriptions. Step therapy requires your doctor to consider alternative medications in those 5 categories before prescribing the higher-cost medications. New drugs could be added from time to time.

		Step therapy drug categories Categories in the step therapy program are: COX-2 Inhibitors (Celebrex) Leukotrienes for Asthma (Accolate, Singulair) Rheumatoid arthritis drugs (Enbrel, Humira, Kineret) ACE Inhibitors (Accupril, Mavik, Altace, Aceon) Angiotensin II receptor blockers (Avapro, Atacand, Cozaar, Diovan)

4. Quantity versus Time, or QvT, is an edit that provides a baseline for the recommended amount of medication that should be taken over a certain period of time. QvT applies to both retail and mail-order prescriptions. When more medication is necessary, BCBSTX must approve the higher quantity. See below for examples of medications in the QvT program.

		Quantity vs. time drugs Certain drugs are limited to a specific quantity for a specific period of time. Some examples are: All nasal inhalers (Flonase) Migraine medications (Imitrex) Asthma inhalers (Albuterol) Pain management (OxyContin) Proton Pump Inhibitors (Prevacid) To find out if a drug you are taking is subject to quantity limits, please contact BlueCross BlueShield of Texas at (800) 521-2227. A complete list can be found online at www.bcbstx.com.

5. Mail-order prescriptions are available for medications you take on a long-term basis. You can order up to a 90 day supply at one time, and pay less than you would pay at your local drug store. Instead of paying 3 times the monthly copayment, you only pay 2 times the copayment — 33 percent savings for you. See the Prescription Coverage chart, which illustrates the savings.

		Mail-order sounds easy sign me up! You can get a 90-day supply of your medication for the cost of a 60-day supply. Ask your HR liaison for a Prime Therapeutics mail-order form.

Prescription Coverage

The HMO and PPO plans provide access to prescriptions through copayments –always lower than paying the old-fashioned 20% coinsurance. That’s because we want you to take the medications you need to get well, or manage your condition.

To find a participating pharmacy, go to www.bcbstx.com and use the pharmacy or provider finder option.

Top 20 prescriptions for employees and retirees

Paying the retail cost for prescription drugs is expensive. But you are spared that expense by the city’s three-tier prescription drug benefit – especially if you use generic drugs.

It’s easy to find what tier your prescriptions are in. Check the chart below to see if your prescription is also one of the top 20 medicines. Then, compare your cost with the retail cost and see how much your plan saves you in out-of-pocket expenses. To see the entire list of preferred drugs, go to www.bcbstx.com,
pharmacy option.

*Step therapy drug.

As always, if the retail cost of the prescription is less than the copayment, you pay the lower amount.