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PRESCRIPTION DRUG BENEFITS: Partners Rx An Introduction to Your Prescription Benefit Program Important Features of Your Prescription Benefit Program Your Prescription Drug Coverage Generics What is a generic drug? Why are most generic drugs less expensive than brand name products? Who manufactures generic drug products? How are generic drugs approved for use? Are generic drugs effective? Are generic drugs safe? Partners Rx Contact Information Getting Started How do I know if my medication requires prior authorization? What if my medication requires prior authorization? Formularies and Three Tier Benefit Design What are formularies Why are formularies necessary? Who decides which medications are on the formulary? How is a medication added or deleted from the formulary? How often are changes made to the formulary? Will my copay be higher if I choose to use a non-preferred medication? How can I find out what drugs are on the formulary? What if my medication is not on the formulary? Most commonly prescribed medications from the Partners Rx Formulary PRESCRIPTION DRUG BENEFITS: Partners Rx An Introduction to Your Prescription Benefit Program Back to top Welcome to your prescription benefit program. This program is administered by Partners Rx, your pharmacy benefit manager. Your prescription benefit program lets you and your eligible dependents obtain prescription medications conveniently and at reasonable prices. A few of the important objectives of this program include: – Providing a high-quality prescription benefit program that meets your needs and the needs of your family – Helping promote the use of safe and cost-effective medications This booklet was developed for you to use as a resource—along with other prescription benefit program resources such as the Partners Rx website (www.partnersrx.com) and the Customer Service telephone line at 1.800.711.4550—to help you understand how the program works and how you can get the most out of this benefit. Please take this opportunity to educate yourself about this important benefit. Important Features of Your Prescription Benefit Program Back to top Some features of this prescription benefit program that will help you use your benefit more effectively are: Generic provision: Under the prescription benefit program, if you choose to receive a brand name drug when a generic drug is available, you may be responsible for your copayment plus the difference in cost between the generic and the brand name drug. Please refer to your benefit document for the specific details of your prescription coverage. Prior Authorization: Prior Authorization may be required for the prescription benefit program to cover certain types of drugs. What is Prior Authorization? Your prescription benefit program may have a Prior Authorization process. Prior Authorization helps ensure that you and your family receive the right care and the right drug to stay healthy. Prior Authorization also helps ensure that the drug you’ve been prescribed is medically needed. Finally, Prior Authorization helps ensure that you receive proper follow-up care. Quantity limits: The prescription drug plan may limit certain medications by dose or number of units to help ensure that the medication is used safely and effectively. Your Prescription Drug Coverage Back to top Generics Back to top Prescription drugs can be a costly part of your medical expense. Americans spend over a billion dollars on prescription drugs each year. One thing you can do to help control health care costs is to consider taking generic medications. For example, the average prescription cost of a generic drug is approximately $25.00 and the average prescription cost of a brand name drug is approximately $114.00. Generic drugs may offer you a better value, while still being safe and clinically effective, and in some cases, offer you a lower copay. A number of questions and concerns have been raised about the quality of generics as compared to brand name products, and you may wonder whether you should take them. The following are answers to some of the more commonly asked questions about generic drugs. What is a generic drug? Back to top A new drug is given two names. One is the brand name, which is what the manufacturer chooses to call the product. The other is the generic name, which is the name of the chemical compound of the drug. Every drug has a generic name to describe its active ingredient. Why are most generic drugs less expensive than brand name products? Back to top When a company develops a new drug, it has a patent for 17 years. The patent protects the drug company’s right to be the only manufacturer of that drug. After the patent expires, other companies can manufacture and sell the drug under either a different brand name or the generic name. Because of lower research costs and more competition, the new product is usually sold at a lower price than the original brand name product. Who manufactures generic drug products? Back to top Many drug companies that manufacture brand name products also manufacture generic products. In fact, many drug companies that manufacture the brand name products also own the company that makes the generic version of their drug. How are generic drugs approved for use? Back to top The Food and Drug Administration (FDA) reviews all brand name and generic products for safety and effectiveness. Before a generic drug is approved for use in the United States, the drug company must provide proof to the FDA that the product has the same active ingredient as the brand name product. In addition, the generic product must meet FDA standards for the amount of active ingredient and speed of absorption into the body. When the generic product meets these standards, it is considered equivalent. Are generic drugs effective? Back to top To gain FDA approval, a generic drug must have the same effect on the body as the brand name product. This means that the generic product must have the same active ingredient and must be the same strength. Sometimes, the generic drug may have a different color or shape than the brand name drug. This has no effect on the medical action of the drug; however, it does help to distinguish one product from another. Are generic drugs safe? Back to top The FDA ensures that all new brand name and generic drugs are safe and effective. The FDA also monitors reports from doctors, pharmacists and nurses on adverse drug reactions. With all drugs, brand and generic, some adverse reactions are possible. Partners Rx Contact Information Back to top
Getting Started Back to top How do I know if my medication requires prior authorization? Back to top A list of covered drugs is in the printed version of the quick reference drug formulary, which is included in this booklet. To obtain a full formulary listing, log on to the Partners Rx Website, www.partnersrx.com. Formulary drugs that require Prior Authorization are identified as such in the full formulary listing; others that are not listed may also require Prior Authorization. Your doctor and pharmacist are provided information regarding the Prior Authorization policies of your prescription drug plan. What if my medication requires prior authorization? Back to top Several options are available to you: – Review your medication and the formulary drug list with your doctor. There may be another drug available on the formulary list that would not require Prior Authorization. – You can ask your doctor to call or fax a Prior Authorization request. The process is very simple for your doctor. The phone number for your doctor to call is included in this booklet. A Prior Authorization request form can also be faxed and is available on the Partners Rx Website under the Healthcare Professionals section. – You can ask your pharmacy to contact your doctor concerning a Prior Authorization request. Your doctor can then call or fax a prior authorization request. – A staff of qualified pharmacists and technicians is available Monday through Friday from 6:00 a.m. to 6:00 p.m. Pacific Time to help your doctor with a Prior Authorization request. Your doctor is notified of a Prior Authorization decision within two business days. Most requests are completed within 24 hours. – Complete information is required to properly review a Prior Authorization request. Your doctor may need to provide information about your diagnosis or drug history. This may include documents, records or lab tests to show that the requested drug is the right treatment for your medical condition. Formularies and Three Tier Benefit Design Back to top What are formularies Back to top A formulary is a list of preferred and non-preferred medications that is covered under your prescription drug benefit and is available to your health care provider to use in your treatment. Most hospitals have used these medication lists for years to control costs while still providing quality medications. Pharmacy benefit managers (PBMs), health plans and even some large medical groups have turned to these medication lists to help reduce rising drug costs. Why are formularies necessary? Back to top Drug costs continue to rise. Formularies list medications that offer the best value without sacrificing quality of care. Reducing rising drug costs helps all of us reduce overall health care costs. Who decides which medications are on the formulary? Back to top Drugs are added to or deleted from the formulary only after careful review by a committee of practicing physicians and pharmacists. This committee, called a Pharmacy and Therapeutics (P&T) Committee, has the duty of reviewing new and existing drugs. This committee decides which drugs provide quality treatment at the best value. How is a medication added or deleted from the formulary? Back to top A drug must first demonstrate safety and effectiveness to be added to a medication list. The cost of a medication is considered only after safety and effectiveness are determined. Some drugs have similar safety and effectiveness and are available at a lower cost. Therefore, the safest, most effective and least costly medication is generally added to the list. How often are changes made to the formulary? Back to top Formularies are dynamic, and changes are made to keep up with new and ongoing research results in the health field. The P&T Committee meets quarterly, and changes may or may not be made to the formulary based on the committee’s review. Will my copay be higher if I choose to use a non-preferred medication? Back to top Your plan may require a higher copayment for non-preferred medications. Check your benefit materials if you have specific questions about your pharmacy benefit. How can I find out what drugs are on the formulary? Back to top You can either visit the Partners Rx website at www.partnersrx.com or call us at 1.800.711.4550. What if my medication is not on the formulary? Back to top Formularies list alternative medications which are safe and effective. The medications often have the same therapeutic effect on your body. If your medication is not listed, ask your doctor or pharmacist for an alternative. Most commonly prescribed medications from the Partners Rx Formulary Back to top Click here to view a PDF file of most commonly prescribed medications from the Partners Rx Formulary. (Requires a PDF reader)
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