Prescription Drugs

There are changes to the prescription drug plan effective May 1, 2005 and they are a result of the rapidly rising price of drugs. The use of prescriptions has been a huge driver of the health-care cost crisis. With the introduction and media marketing of new high-tech/high-dollar drugs, the cost of prescriptions continues to soar out of control.

The city’s prescription drug plan pays for drugs that help cure diseases, relieve suffering and prolong life, but certain drugs that are not in these categories will be dropped from coverage effective May 1, 2005. They are:

Non-sedating antihistamines, such as Zyrtec, Allegra, and Clarinex. 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. Click here for a complete list.

Prescription drugs and devices used to treat sexual dysfunction, such as Viagra, Cialis, and Levitra. These drugs can still be obtained, but you will pay the full cost. Click here for a complete list.

Step therapy will be introduced into the prescription program.

How Does Step Therapy Work?

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.

Prior to May 1, HMO Blue Texas will send a notification to everyone who is currently taking a Step Therapy drug, so you will have time to discuss alternatives with your doctor.
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 a Step Therapy drug without approval, you will pay the generic copay plus the difference in cost between the brand name and the generic.

Categories now in the step therapy 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 blockers (Avapro, Atacand, Cozaar, Diovan)

Click here for a detailed description

*HMO Blue Texas periodically reviews covered drugs and can modify the Step Therapy program.

Prescriptions as a Percent of Total Claims

This chart shows the history of presciption costs.

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Prescription Coverage

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Generic Drugs

As you know, prescription drug usage has been identified as one of the major contributors to the health-care cost crisis, and one way of deflating these sky-rocketing prices is to reduce the demand. Buy generic whenever possible.

All generic drugs are covered in tier one of the three-tier formulary, at $10 copayment rate. The next time you go to the doctor, take a copy of the preferred-drug list with you and ask your doctor about a generic if there is one available.

The effectiveness of generic drugs is the same as the over-advertised, highly priced name-brand drugs in nearly every way except for the lower price tage. Remember, your copayment is only $10 for a 30-day supply of a generic drug.

In the chart below are some examples of these cost differences.

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Preferred Drug Program

The city implemented a three-tier program for prescription drugs in July 2002. You find the lowest copayment when you purchase generic drugs. If you want a brand-name prescription, look in the “preferred” category for the lowest price on brand name drugs. Other prescriptions are available in the non-preferred category, but your copayment will be higher. (See chart below.)

As a reminder, brand-name drugs may move from the nonpreferred tier to the preferred. Most of these changes are limited to one time per year, in May. Be sure to check the preferred drug list before you refill your prescriptions. A current list is found at www.bcbstx.com, or call (713) 837-9400.

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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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Top 25 Prescriptions

Paying the retail cost for prescription drugs is expensive. But you are spared that expense by the city’s three-tier prescription drug benefit – especially if you use generic drugs.

It’s easy to find what tier your prescriptions are in. Check the chart below to see if your prescription is also one of the top 25 medicines. Then, compare your cost with the retail cost and see how much your plan saves you in out-of-pocket expenses.

To see the current list of preferred drugs, go to www.bcbstx.com, pharmacy option

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