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Prescriptions Rules of the Game
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Prescription plan highlights

You’ve managed this game so well, we can continue the prescription benefit with only a couple of program notes. And for the most part, prescription benefits will stay the same. This is a three-tier prescription plan, with different copayments in each tier. The brand name copayments will increase by $5, making preferred brand $35 and non-preferred brand $50. Drugs are assigned to the tiers based on the BCBSTX formulary, which can change annually, usually in May. To find out which drugs are in each of the three tiers, go to www.bcbstx.com.

Prescription copayments

 

Retail pharmacy
(30-day supply)

Mail-order pharmacy
(90-day supply)

Generic $10 $20
Preferred brand $35 $70
Non-preferred brand $50 $100

 

Reviewing the rules of the Rx game

Mandatory generic
The mandatory generic feature calls for filling your prescription with a generic drug if one is available. Remember, generic drugs are copies of brand-name drugs, identical in dosage, safety, strength, quality, performance and intended use. If you still prefer the brand-name drug when a generic is available, you will pay extra.

How mandatory generic works

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 Metoprolol Tartrate $30.66
You purchase brand-name Lopressor HCT $170.06
Difference in price $139.40
Your cost = price difference + $10 generic copayment $149.40

Mail order
Through BCBSTX’s mail-order pharmacy, Prime Therapeutics, you can order a 90-day supply for the price of a 60-day supply.

To switch your maintenance prescriptions to Prime Therapeutics and save 33 percent, get a mail-order form from www.bcbstx.com or request HR benefits send one to you.

What is step therapy?
To save you and the city money, the plans require your doctor to try a generic prescription before prescribing a higher-priced brand drug. If the alternative drug fails to alleviate your condition, your doctor can request authorization to step you up to the more-costly prescription.

Step therapy
The step-therapy feature saves you money by requiring your doctor to consider alternative medications before prescribing higher-cost medications in seven categories:

  • Proton pump inhibitors for GERD, heartburn and stomach ulcers (Nexium, Prevacid, Protonix)
  • Statins for high cholesterol (Lipitor, Vytorin, Zocor)
  • COX-2 inhibitors for inflammation/pain (Celebrex)
  • Leukotrienes for asthma (Accolate, Singulair)
  • Rheumatoid arthritis drugs (Enbrel, Humira, Kineret)
  • ACE inhibitors for high blood pressure/congestive heart failure (Accupril, Mavik, Altace, Aceon)
  • Angiotensin II receptor blockers for high blood pressure (Avapro, Atacand, Cozaar, Diovan)

New drugs may be added periodically.

Quantity versus time
Certain drugs are limited to a specific quantity over 30 or 90 days. This is called quantity versus time and applies to retail and mail-order prescriptions, including nasal and asthma inhalers, migraine medications, pain-management medicines, proton pump inhibitors, and others. When more medication is necessary, BCBSTX must approve the higher quantity. The list of drugs that are subject to quantity limits can change. To find an updated list, visit www.bcbstx.com or call 800-521-2227.

Triessent Specialty Drug Program
High-cost specialty drugs, such as Enbrel or Tracleer and those administered through home infusion, are available exclusively through the Triessent Specialty Drug Program. Once you have signed up, Triessent will send a 30-day supply of the specialty medication to your home, your designated address or your doctor’s office each month. The 30-day supply will cost you just $35 or $50. Call (888)-216-6710 to sign up for the program.

Top 10 prescriptions by amount spent

Drug / Treatment

Your copayment

Plan pays

1 Lipitor* / cholesterol $50 $155
2 Plavix / stroke and heart attack $35 $200
3 Actos / diabetes $35 $255
4 Enbrel** / rheumatoid Arthritis $35 $2,062
5 Nexium* / GERD $35 $224
6 Crestor* / cholesterol $35 $149
7 Valtrex / herpes Virus $35 $260
8 Humira** / rheumatoid Arthritis $35 $2,033
9 Advair diskus / asthma $35 $234
10 Tricor* / cholesterol $35 $153

NOTE: top 10 list is for HMO only - 12/31/2009.
*Step-therapy drug.
**Specialty drugs must be ordered through Triessent

 

Prescription as percent of total claims

A winning strategy

Want to save even more on your prescriptions? Wal-Mart, Sam’s Club, Target, H-E-B, Walgreens, Randalls and Kroger offer 30-day supplies of hundreds of generic medications for just $4 or $5. That’s half or less than your prescription drug copayment, saving you up to $72 a year per discounted medication. Discounted drugs include those for asthma, depression, diabetes, heart disease and glaucoma among many others.

To view the list of medications available for $4 or $5, visit the following Web sites:

www.walmart.com/pharmacy
www.target.com/pharmacy
www.kroger.com/generic
www.randalls.com
www.heb.com/pharmacy
www.walgreens.com


 

 
 
 
 
 
 

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If there exists a conflict between this Enrollment Guide Website and the official plan documents for each plan, the official plan documents will prevail. The city of Houston reserves the right to change, modify, increase or terminate any benefits.