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PRESCRIPTION DRUG BENEFITS MedImpact regional participating pharmacies MedImpact three-tier benefit plan - Introduction MedImpact three-tier benefit plan - Factors driving drug costs MedImpact three-tier benefit plan - Three-tier breakdown Talk to your doctor about your prescriptions Hypothetical example of how drug choices affect your out-of-pocket costs Save time and money with Walgreens Mail Service Pharmacy Program Walgreen's Mail Service Program: For new prescriptions Walgreen's Mail Service Program: For Refills FREQUENTLY ASKED QUESTIONS What is a formulary? Are generic drugs as good as brand drugs? Are all drugs within a class equally effective at treating my condition? How can I get a list of covered drugs? How does MedImpact determine if a drug is Preferred (Tier 2)? What should I say to my doctor when I talk to him about my drug plan? How is the prescription drug program helping me? What if my medication is not listed on this guide? What happens if I get a brand name drug when a generic is available? MedImpact regional participating pharmacies Balin's Tower Drug & Gift Bi-Mart Campus Drug Clinic Pharmacy Costco Drug Mart Fred Meyer Hans Pharmacy Howard's Drug K-Mart Magill Drug Co. Pharmacy Express Pill Box Rite Aid Safeway Pharmacy Sav.on Pharmacy Shopko Sisters Drug Co., Inc. St. Charles Medical Center Outpatient Pharmacy The Medicine Shoppe Thornton's Rexall Drug Thrifty Drugs Walgreens Wal-Mart Note: There are over 59,000 retail pharmacies to choose from nationwide. To locate the nearest pharmacy, please call (800) 788-2949 or log on to www.medimpact.com. Member Only. MedImpact three-tier benefit plan - Introduction Our goal is to provide you with a high quality benefit for your prescription drug coverage, in addition to be able to better manage costs while offering you choices. Spending on prescription drugs may reach a projected $184 billion in 2008, up from $62.2 billion spent in 1996. MedImpact three-tier benefit plan - Factors driving drug costs The dynamics contributing to rising pharmaceutical costs include: - Total drug spending more than tripled between 1990 and 2001. By 2002, spending on prescription drugs reached $162.4 billion (10.5% of total health spending). In 2004, pharmaceutical costs had climbed by 7.2% over the previous year. - Direct-to-consumer advertising accounted for 12%, or $2.6 billion, of total growth in drug spending during 2000, driving drug costs higher. - In the last decade, the FDA has approved more than 300 new prescription drugs including treatments for many life-threatening conditions such as heart disease, diabetes, HIV/AIDS, cancer, and many more. - As our population lives longer, drug costs rise. Contributing to this is the expanded utilization of maintenance drugs and the rising sales of costlier drugs. MedImpact three-tier benefit plan - Three-tier breakdown Three Tier Prescription Drug Benefit Delivers Choice and Flexibility. MedImpact prescription drug benefit includes three categories of prescription medications with corresponding pricing levels. This structure allows for more choice and access for our members. Tier 1 - Generic Drugs (lowest copay): Generic drugs offer an excellent value to the consumer because they are chemically equivalent to brand drugs but are priced at a fraction of the cost of the corresponding brand drug. We encourage you to use a generic drug whenever it is available and allowed by your practitioner. It can save you money, as generic drugs are covered with the lowest copay. Tier 2 - Preferred Brand Drugs (mid-level copay): Within a class of drugs, there are often several brand name drugs protected by separate patents. Each of these are equally effective for treating a particular condition and all are FDA-approved for use in treating the condition. Pricing of these various medications can differ significantly, often because of the pharmaceutical company's marketing efforts. Certain drugs that MedImpact identifies as Preferred Brand Drugs are available to members at a lower copay than Tier 3 drugs. Members can still get the medication they need while saving money. Tier 3 - Non-Preferred Brand Drugs (highest copay): Once the FDA approves a drug, its manufacturer will usually try to protect the product by obtaining a patent for it and giving it a brand name. This allows the manufacturer to gain exclusive marketing rights and therefore charge a high price for its product. Drugs in this category will usually have generic equivalents found in Tier 1, with your lowest copay. Talk to your doctor about your prescriptions When you decide to purchase a medication, it is important to consider the cost of alternatives available. In many cases, you may select a preferred brand or generic drug in order to pay a lower copay, and be assured that the medication is equally effective in treating your condition. Before your physician writes your prescription, you are encouraged to discuss the various drug options available. Your physician can help you save money by choosing a prescribed medication that falls in the generic brand or preferred brand tier. MedImpact makes its current list of preferred brand drugs available to participating providers and to you so that together you can agree on the best drug treatment. Hypothetical example of how drug choices affect your out-of-pocket costs John Smith, a MedImpact member, has an appointment with Dr. Jones to receive a prescription for his arthritis pain. The doctor has decided to prescribe a drug from a class of drugs known as non-steroidal anti-inflammatory drugs (NSAID). There are many choices within this class that Dr. Jones and Mr. Smith can agree upon. Listed below is an example of Mr. Smith's three-tier prescription drug benefit. The decision that is made will reflect the difference between paying $10 for a generic, $20 for a preferred brand or $40 for a brand drug. Tier 1 Generic drugs: $10 copay 1. Ibuprofen 2. Naproxen Tier 2 Preferred Brand drugs: $20 copay 1. Daypro 2. Relafen Tier 3 Brand drugs: $40 copay 1. Anaprox 2. Voltaren Save time and money with Walgreens Mail Service Pharmacy Program Certain pharmacy benefit programs are eligible for mail-order services; please review your benefits to determine if you have mail-order coverage. For your convenience, you can have prescriptions mailed to you. If you are on a long term, maintenance medication, this will save you money. Prescriptions are delivered to your home in sealed, tamper evident, discreetly labeled packaging. You pay no packaging or postal costs. The Three Tier copay structure applies when you use Walgreens Mail Service Program. When you receive drugs at a participating retail pharmacy, you pay one copay for each 30 day supply. With Walgreens Mail Service Program, the copayments are higher, but you pay only one copayment for up to a 90 day supply. Important note: This mail service benefit is only provided through Walgreens Mail Service Program. If your prescription is mailed to you by a participating retail pharmacy, the retail copays will apply. Use of any other mail order program will result in benefits paid at the level of a non participating pharmacy. Walgreen's Mail Service Program: For new prescriptions Obtain a Walgreens Mail Service registration brochure from your company benefits department or contact Preferred Health customer service. In Deschutes County call (541) 312-0018 In Klamath County call (541) 882-1466 And all other areas call toll free (800) 303-8680 Complete and submit prescription with your initial order form. Mail: Walgreens Mail Service, PO Box 29061, Phoenix, AZ 85038-9061 Telephone: 1-866-304-2846 FAX: Physician fax to (800) 332-9581 Internet: www.walgreensmail.com Get a mail-order form Walgreen's Mail Service Program: For Refills Telephone: 1-800-797-3345 Mail: Walgreens Mail Service PO Box 29061, Phoenix, AZ 85038-9061 Internet: www.walgreensmail.com Get a mail-order form We recommend allowing two weeks for delivery; therefore, it is best to order your refill three weeks in advance of when you need it. FREQUENTLY ASKED QUESTIONS Q. What is a formulary? A. A formulary is a list of safe and cost effective drugs, chosen by a committee of physicians and pharmacists. Formularies have been used in hospitals for many years to help ensure quality drug use. The MedImpact formularies are continually revised to reflect the changing drug market. The level of copayment is commonly referred to as a three-tier benefit. Please refer to your pharmacy benefit description to see your specific drug coverage/exclusion list and to determine the copayment amounts based on your pharmacy benefit. Q. Are generic drugs as good as brand drugs? A. Yes. The FDA requires a drug manufacturer to show that a generic version of a brand drug is as safe and effective as its counterpart because the drug: - Enters the bloodstream to the same extent as the brand name; -Contains the same amount of active ingredients; -Is provided in the same dosage form; and -Is taken the same way. Q. Are all drugs within a class equally effective at treating my condition? A. Usually. Your doctor will know whether other drugs within a class are equally effective for treating your condition. Q. How can I get a list of covered drugs? A. A copy of MedImpact's complete list of covered drugs for the Select Formulary can be found on the MedImpact website (www.medimpact.com) and is available from Member Services at (800) 788-2949. If you have questions or need more information, please: - Ask your physician to discuss the list with you. - Call the number on the back of your pharmacy ID card and speak to a Member Services representative. For information on the Custom (Closed) Formulary, please call Preferred Health Customer Service: in Deschutes County call (541) 312-0018; in Klamath County call (541) 882-1466; and all other areas call (800) 303-8680 toll free. Q. How does MedImpact determine if a drug is Preferred (Tier 2)? A. A drug becomes Preferred if the Pharmacy & Therapeutics (P&T) Committee recommends a drug as both clinically and financially superior. The drug list is reviewed and updated regularly by adding the latest safe and effective drugs and removing those that are no longer as effective. Q. What should I say to my doctor when I talk to him about my drug plan? A. You should inform your physician that you now have a three tier pharmacy benefit copay, and show him/her the listing mailed to you. Ask the question, "Are there generic drugs or Tier 2 drugs appropriate for my medical condition?" Q. How is the prescription drug program helping me? A. Due to the dramatic increase in drug costs, Preferred Health and MedImpact strive to develop new ways to help alleviate the financial costs to employers and individuals so we can continue to offer drug benefits to our members. Q. What if my medication is not listed on this guide? A. 1. All generic drugs are included on the formulary, though only some are listed due to space limitations. Most prescription drug programs cover generic medications at the lowest copayment. 2. Your medication is not a formulary medication and may be covered at the highest copayment. 3. Your medication is not a covered drug. 4. Your medication may have been added to this list after it was printed. If you believe your medication is not on the formulary, please discuss formulary alternatives with your physician. Q. What happens if I get a brand name drug when a generic is available? A. There may be situations when you or your practitioner selects a Brand name drug even when a generic is available. Your physician would be contacted to submit proof that the generic equivalent is not tolerable. If approved, you will be charged the Tier 3 copayment; if denied due to the generic or Tier 2 drug being tolerable, you would be responsible for the Tier 3 copayment, plus the cost difference between the generic and Brand name drug. For those with the Select Formulary pharmacy benefit program, you may choose to request a Brand name drug even when a generic equivalent is available and allowed by your practitioner. In this case, you will be responsible for paying the difference in price, plus the applicable copay. | ||||||
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