Three-tier Benefit Design FAQ
What is a three-tier benefit design?
A three-tier benefit design is a prescription drug benefit with three different copay levels, based on the medication purchased. This program promotes the use of a prescription drug formulary (which will also be referred to as a preferred medication listing) to help keep prescription drug costs under control for all of us. Your three-tier benefit design works this way:
Tier 1: Generic drugs (the least expensive copay)
Tier 2: Formulary brand drugs (a more expensive copay)
Tier 3: Non-formulary brand drugs (the most expensive copay)
How does this benefit design affect me?
Your copay is determined by the tier in which your prescription drug falls. You will have the least out-of-pocket copay expense for generic drugs; a larger out-of-pocket copay expense for brand drugs on the formulary; and the largest out-of-pocket copay expense for brand drugs not on the formulary.
The preferred medication listing applies only to outpatient prescription drugs covered under your program. It does not apply to inpatient medications or to medications administered in a doctors office. It is important to inform your doctor of your three-tier benefit design. Take your preferred medication listing with you when you visit your doctor in case your doctor prescribes a medication. Then, he or she can prescribe the most appropriate medication for you from the listing.
It is important to remember that the three-tier design does not eliminate coverage for any drugs. It does, however, require greater out-of-pocket expenses for those drugs not on the preferred medication listing.
What is a formulary/preferred medication listing?
The formulary is a regularly updated list of generic and brand prescription medications that have been reviewed and are considered to be cost-effective choices for care. The preferred medication listing will be routinely reviewed and updated by the Prescription Benefit Management Companys Pharmacy and Therapeutics (P&T) Committee.
Prescription drugs are selected for inclusion on the preferred medical listing, based on safety, clinical effectiveness and cost factors. The listing will assist in maintaining the quality of patient care and containing the cost of prescription drugs. The list is updated periodically.
How are drugs selected for the listing?
A P&T Committee selects medications for the preferred medication listing. The P&T Committee is an independent committee made up of practicing doctors in various medical specialties, community pharmacists, clinical pharmacists and other health care professionals. The committee reviews scientific literature and reports, consults with other health care professionals and uses their expertise to determine which medications should be added and deleted from the listing.
What criteria are used to select drugs for the preferred medication
The P&T Committee reviews each medication for:
Effectiveness (ability in treating a disease or symptom)
Uniqueness (how does the drug compare to other drugs?)
Once drugs meet these criteria, the P&T Committee will consider the cost of the drug.
Why do formulary generic drugs have a lower copay than formulary
Generics are typically less expensive than their brand-name equivalents. The average cost for a 30-day supply of a brand drug is about $70, while the average cost of a generic medication is about $20. Many brand name drugs cost more than $100 for a 30-day supply. For this reason we are able to make generic drugs available at a lower copay amount.
Are generic drugs the same as brand name drugs?
Yes. The Food & Drug Administration (FDA) evaluates each generic version of a brand drug to ensure the active drug is the same, it contains the equal amount of drug, it is released into the body at the identical rate, and it has the same action in the body. The FDA uses the same scrutiny in evaluating generic drugs as it does with brand drugs. Generics become available after a brand name patent expires.
Why are some brand drugs selected for the listing while others
The first priority for the doctors and pharmacists on the P&T Committee is to ensure that the drug is as safe and effective as other drugs within that class. If a drug is as safe and effective as an alternative drug, it makes sense to choose the less expensive drug for the preferred medication listing.
What if my doctor says I have to use a non-formulary brand drug.
Do I still have to pay the highest copay amount?
Non-formulary drugs are still covered. You will, however, have to pay the greatest copay amount. This amount will still be less than the full cost of the prescription drug, which some other drug programs require their customers to pay if a drug is not listed on the preferred medication listing.
Who do I contact for an updated listing?
For the most up-to-date listing of our formulary, see Prime's online drug formulary. Here, you can search for a particular drug by name. If the drug name does not appear, it is not a formulary drug and you will be responsible for the greatest out-of-pocket copay amount. You may also call TELEORDER, our 24-hour request line, for an updated formulary. To use TELEORDER call the toll-free number, 1-800-346-2227. Topeka residents should call 785-291-8130.
Who do I contact if I have more questions?
If you have questions, you may contact BCBSKS at 1-800-432-3990. We will be happy to assist you.