Pharmacy Benefit Changes Effective July 1, 2009

The State Health Plan is revising prescription tiers, copayments, and coverage of specialty medications as part of the pharmacy benefit changes for the next fiscal year.

Revised Copays

Effective July 1, 2009 the prescription copays for a 30-day supply of medication are: $10 for generics, $35 for preferred brands without a generic available and $55 for non-preferred brands without a generic available.

	Up to a 30 day supply	31-60 day supply	61-90 day supply
Tier 1 Generics	$10	$20	$30
Tier 2 Preferred Brand, without a generic available	$35	$70	$105
Tier 3 Non-preferred Brand, without a generic available	$55	$110	$165
Brand name drug, with a generic available	Members will be required to pay the generic copay, plus the difference between the Plan’s cost of the brand name drug and the Plan’s cost of the generic drug.
Specialty medications	25% coinsurance up to $100 for each 30-day supply (refer to list of specialty drugs at www.shpnc.org)

Brand Name Drug with Generic Available Copay Change

For brand name drugs with an available generic, members will be required to pay the generic copay, plus the difference between the Plan’s cost of the brand name drug and the Plan’s cost of the generic drug. Please Note: There will be no exceptions, regardless of how a physician writes the prescription, even if stated “Dispense as Written” (DAW). This copay and drug cost difference will apply to the $2500 prescription copayment maximum.

Prescription Drug Benefit Changing to a 30-Day Supply

Beginning July 1, 2009, the copay for prescriptions will be for a 30-day supply, instead of a 34-day supply. For convenience, members can now receive up to a 90-day supply of covered medication at any participating retail network pharmacy or Medco By Mail (with the applicable copay).

For more information on these pharmacy benefit changes, please see the Frequently Asked Questions.

Pharmacy Benefit Changes for Specialty Medications

Beginning July 1, 2009, State Health Plan members must use Accredo for all non-acute specialty medications currently filled at retail pharmacies and covered under the pharmacy benefit. If a member uses a pharmacy other than Accredo to purchase any of the non-acute specialty medications listed, they will be responsible for paying the total amount of the prescription at the time of purchase. Medications used to treat cancer are not affected by this change. Please refer to the list of impacted medications.

Also as of July 1, 2009, the copay for all specialty medications will require the member to pay 25% coinsurance up to $100, for each 30-day supply.

Please visit the Specialty Medications Web page for more information on specialty medications and Accredo. You may also see the Frequently Asked Questions.

For questions regarding prescription benefits, please call Medco Customer Service at 1-800-336-5933.