Medicare Advantage Plans Prescription Drugs

Most of the top 50 drugs used by retirees are covered in both Medicare Advantage plans. Both plans have familiar-looking prescription benefits because they resemble the HMO and PPO drug plan. In either plan, you will still have access to medication necessary to manage your health.

Since we’ve had such effective results using the three-tiered formulary, those features, in general, have been repeated in both Medicare Advantage plans. You will have three formularies, or preferred drug lists, to study.

The two Medicare Advantage plans offer the same copayment structure as the city’s familiar HMO and PPO plans. However, both TexanPlus and Texas HealthSpring have an annual $4,000 cap for brand-name prescriptions. Both plans offer unlimited generic prescriptions. Both plans allow for mail-order prescriptions at the familiar mail-order copayment structure.

All prescriptions must be purchased from participating pharmacies or the mail-order facility.

Prescription features

This chart shows the history of presciption costs.

	Three tier copayment stucture. Copayments are the same as in the HMO Blue Texas HMO and PPO.
	Each plan has an approved list of drugs. Be sure to check each list enclosed in your enrollment packets to find your drugs.
	Get your prescriptions from a participating pharmacy, such as CVS or Walgreens. (See chart on page 11.)
	Mail-order prescriptions are sent to: HMOBTX - Prime Theraputics TexanPlus - Caremark Texas HealthSpring - Express Scripts.
	No annual dollar limit on the generic drugs you use.
	$4,000 limit on brand-name prescriptions.
	In Texas HealthSpring, you need to see your PCP before you can get a refill of your current prescriptions.

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Prescriptions as a Percent of Total Claims

In this plan year, the city expects to spend $32 million on prescriptions for all plan members. As shown in the chart below, 46 percent, or $14.7 million, is for retirees.

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Prescription Copayments

Your prescription drug coverage has not changed.

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Mail-order Pharmacy

Prime Therapeutics is the mail order pharmacy (PrimeMail Pharmacy) for the HMO and PPO plans. Ordering your maintenance medications vial mail is a convenient and cost-effective way for you to obtain prescription maintenance medications. You will receive a three-months’ supply of your prescription at the two-month copayment rate. PrimeMail offers several advantages, including convenience, privacy, maximum days supply and timely refills to ensure consistent drug therapy. So, if you are on a maintenance medication (i.e., for high blood pressure, high cholesterol, diabetes, etc.), save yourself some money by ordering through the mail.

Once you’ve started using Prime Mail Pharmacy, you can order refills through www.MyRxHealth.com, the members-only website. If you have any questions about Prime Therapeutics or the mail order drug opportunity, contact the City Benefits Division at (713) 837-9400 or Prime Therapeutics (HMO Blue Texas) at (877) 357-7463.

Mail order forms to: Blue Cross Blue Shield of Texas, c/o PrimeMail Pharmacy, P.O. Box 650041, Dallas, TX 75265-0041.

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What's new on May 1 ... for prescription coverage

To keep the plans affordable for employees and retirees, there are a few changes to your prescription coverage that will take place on May 1, 2005 for those in the HMO Blue Texas HMO and PPO.

Prescriptions benefits:
Non-sedating antihistamines, such as Zyrtec, Allegra, and Clarinex will not be covered by the prescription drug plan. Over-the-counter (OTC) brand name and generic non-sedating antihistamines are available at low cost at all local pharmacies. They are usually less expensive than a prescription copayment.

Prescription drugs and devices used to treat sexual dysfunction will not be covered by the prescription drug plan. These drugs include, but are not limited to, Viagra, Cialis, and Levitra.

Step therapy will be introduced:
Before filling certain prescriptions, the pharmacist will review your prescription history to determine if the plan requires your doctor to consider acceptable alternatives. If so, the pharmacist will advise you to contact your physician to obtain an alternative prescription or to discuss possible over-the-counter solutions.

If it is medically necessary for you to use a drug in the Step Therapy program without trying an alternative solution, your physician can obtain authorization from HMO Blue Texas. If the prescription is approved, you will pay the plan’s copayment of $30/preferred brand or $45/non-preferred brand. If you purchase it without approval, you will pay the generic copay plus the difference in cost between the brand name and the generic. Drugs now in the program are*:

COX-2 inhibitors (Celebrex, Bextra)
Leukotrienes for asthma (Accolate, Singulair)
Rheumatoid arthritis drugs (Enbrel, Humira, Kineret)
ACE inhibitors (Accupril, Mavik, Altace, Aceon)
Angiotensin II receptor blocker (Avapro, Atacand, Cozard, Diovan)

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Top ten retiree prescriptions

The chart below shows the top 10 medicines taken by retirees as of Oct. 31, 2004, and their coverage under the HMO, TexanPlus and Texas HealthSpring.

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