Preferred Drug List Frequently Asked Questions

• How are the drugs selected for the Preferred Drug List (PDL)?
• How often does the Preferred Drug List (PDL) change?
• How are the decisions made to change drugs to different tiers on the Preferred Drug List?
• Whom do I call to ask questions concerning the preferred drug list?
• How can I save money by choosing generic drugs?
• What is the difference between a generic alternative and a generic equivalent drug?
• What if I cannot take a generic medication that is on the preferred drug list? Can I still take a brand name drug for the generic copay?
• Do my pharmacy benefits cover any over-the-counter (OTC) medications?
• The printed PDL appears to be out of date. Where can I find an updated list?
• Can I appeal a copay change on my prescription to the State Health Plan?

How are the drugs selected for the Preferred Drug List (PDL)?

Medications are selected for the Preferred Drug List (PDL) based on their safety, clinical effectiveness and cost savings opportunities. The Preferred Drug List is reviewed and updated on a quarterly basis for new generics and for opportunities to keep the prescription benefit affordable.

How often does the Preferred Drug List (PDL) change?

The preferred drug list is updated quarterly with new generic and brand drugs added, and there may be some drugs moved to the non-preferred copay tier. Affected members are notified if a tier change would increase copays.

How are the decisions made to change drugs to different tiers on the Preferred Drug List?

If a generic version of a brand name medication becomes available, the generic is moved to Tier 1. Because a generic alternative is available, the brand name medication is still covered, but it has a higher out-of-pocket cost: the Tier 1 copay plus the difference in the cost to the Plan between the generic and brand name drug, not to exceed $100 per 30-day supply of the brand name medication.

As new drugs come to the market, they are reviewed for efficacy, safety, and cost as compared to other available preferred drugs and considered for addition to the PDL.

Other drugs may be reviewed and moved to the non-preferred copay tier if there are many generic or brand alternatives.

Whom do I call to ask questions concerning the preferred drug list?

Members may call Medco Member Services at 800-336-5933 for specific questions regarding the Preferred Drug List. Always remember to consult your provider to see if a generic or preferred brand name medication would be appropriate. In addition, members may also contact Medco and ask to speak to a pharmacist about medication options.

How can I save money by choosing generic drugs?

Members may save money by using generic medications because generic medications are covered with a Tier 1 copay versus a Tier 2 or Tier 3 copay for brand name medications. The most expensive medications are those that have a generic equivalent, which require the member to "pay the difference."

Many popular brand name drugs now have generic equivalents that provide the same benefit as their brand name counterparts, with a significantly lower copay. Click here for a list of recently released generic medications.

What is the difference between a generic alternative and a generic equivalent drug?

A generic equivalent is a medication that contains the same active ingredients in strength and purity as the brand name drug.

A generic alternative is a generic medication in the same therapeutic class as a brand name product.

What if I cannot take a generic medication that is on the preferred drug list? Can I still take a brand name drug for the generic copay?

We recognize that a number of patient-specific variables, which are not available to us, must be taken into consideration when a provider prescribes any medication. We also believe that providers are best qualified to balance their patients' quality and cost-of-care considerations in choosing the most appropriate medications. However, copays are set for each medication and are not adjusted for patient-specific cases.

The Plan strives to maintain the most affordable and clinically effective Preferred Drug List for its members. Members and their providers have a choice of using drugs on the preferred list, whenever appropriate. Members should take their PDL with them to every provider visit in order to make the most informed choices.

Do my pharmacy benefits cover any over-the-counter (OTC) medications?

Some OTC heartburn medications (proton pump inhibitors) are covered under your pharmacy benefit with a written prescription from your provider. Click here for more information. In addition, due to recent legislative language, the Plan may elect to not cover a prescription drug if there is a therapeutic equivalent available over-the-counter.

The printed PDL appears to be out of date. Where can I find an updated list?

To view or print a complete, up-to-date Preferred Drug List at any time, click here.

Can I appeal a copay change on my prescription to the State Health Plan?

No, pharmacy copays are not appealable since these are set benefit amounts. Benefit cost structures are not adjusted on a case-by-case basis.