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 doctor’s 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 Company’s
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
listing?
The P&T Committee reviews each medication for:
• Safety
• 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
brand drugs?
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
are not?
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.