Pharmacy Benefit Changes Frequently Asked Questions

The following FAQs answer some common questions about the changes in your prescription drug benefits.
  1. When will changes to my pharmacy benefit take effect?
  2. Why is the State health Plan decreasing the days supply from 34 to 30 days for prescriptions?
  3. Are the copays for prescription medications changing?
  4. Why did the copays increase on every drug tier except the $10 generic tier?
  5. Why such an increase for brand name drugs and Specialty medications?
  6. I have tried the generic brands and they do not work for me. My doctor has only prescribed brand name medication. Can I appeal my pharmacy copay if I cannot tolerate the generic version? Can I appeal the copay and get my prescriptions for $10?
  7. I do not understand what my out-of-pocket expense will be if my prescription for a brand name drug has a generic equivalent available. Do you have an example?
  8. How will I be able to find out what the difference in cost is going to be before I get to the pharmacy to pick up my prescription?
  9. Do all copays and medication costs apply to the $2500 maximum?
  10. Are there any drugs exempt from “paying the difference”?
  11. Are there any changes to the State Health Plan’s special copay programs?
  12. Will there be any changes in the cost of diabetic supplies?
  13. Why was I paying less than my copay for some drugs since July and now the cost has increased to the copay?

1. When will changes to my pharmacy benefit take effect?
July 1, 2009.

2. Why is the State health Plan decreasing the days supply from 34 to 30 days for prescriptions?
By changing to the industry standard 30/90 prescription benefit, the State Health Plan hopes to reduce medication waste when dosages change.  Members will now be able to receive up to a 90-day supply of covered medication at any participating retail network pharmacy or Medco By Mail (with the applicable copay).

3. Are the copays for prescription medications changing?
The copays for all tiers of prescriptions are changing, with the exception of generic medications.  The following chart shows the new copays for prescription medications:

  

New Copays Effective July 1 2009

Prescription Drug Tiers

Current Copay (to June 2009)

Up to a 30 day supply

31-60 day supply

61-90 day supply

Tier 1
Generics

$10

$10

$20

$30

Tier 2
Preferred Brand,
without a generic available

$30

$35

$70

$105

Tier 3
Non-preferred Brand,
without a generic available

$50

$55

$110

$165

Brand name drug,
with a generic available

$40

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

$10, $30, $40 or $50 (based on Tier level)

25% coinsurance up to $100 for each 30-day supply
(refer to list of specialty drugs at www.shpnc.org)


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4. Why did the copays increase on every drug tier except the $10 generic tier?
Most State Health Plan members have found that using generic medications has reduced their out-of-pocket expenses.  Member adherence to medications for chronic illnesses has also increased.  The Plan wants to continue to provide options that will not only save health care dollars for the member and the Plan, but also promote the importance of medication adherence.

5. Why such an increase for brand name drugs and Specialty medications?
The copay increases were implemented to help control the rising cost of medications, and to maintain an affordable prescription drug benefit. However, in this process some members will see their out-of-pocket expenses increase due to the copay change.

Also remember that your out of pocket maximum for pharmacy remains at $2500 per benefit year.  If you spend more than $2500 for your prescriptions between July 1 and June 30, your prescriptions will be covered at 100%.

6. I have tried the generic brands and they do not work for me. My doctor has only prescribed brand name medication. Can I appeal my pharmacy copay if I cannot tolerate the generic version? Can I appeal the copay and get my prescriptions for $10?
No, copays cannot be appealed.  Copays are considered a level of benefit and therefore, cannot be appealed.

7. I do not understand what my out-of-pocket expense will be if my prescription for a brand name drug has a generic equivalent available. Do you have an example?
For brand name drugs with an available generic, members will be required to pay the generic copay of $10, 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). Members will never pay more than the total cost of the medication.
 
        Example:     Drug A
        Brand name drug cost to the State Health Plan                        $100
        Generic drug cost to the State Health Plan                                  $20
        Difference in cost to the State Health Plan                                   $80
        Plus Generic level copay                                                               $10
        Total member responsibility for Brand name drug A,
        with a generic available                                                        $90.00

8. How will I be able to find out what the difference in cost is going to be before I get to the pharmacy to pick up my prescription?
Beginning July 1, you may contact Medco customer service at 1-800-336-5933 and a representative will assist you.  In addition, members will also be able to visit “My Rx Choices” at www.medco.com to check the price of your medication before you pick up your prescription.  Members are encouraged to discuss the generic equivalent options for  your prescriptions with your physician.

9. Do all copays and medication costs apply to the $2500 maximum?
Yes, all copays including specialty and any cost difference paid for brand drugs when a generic equivalent is available are applied to the $2500 maximum.

10. Are there any drugs exempt from “paying the difference”?
Narrow Therapeutic Index (NTI) drugs, such as Coumadin and Lanoxin, as well as Specialty drugs, are not subject to the member paying the difference.

11. Are there any changes to the State Health Plan’s special copay programs?
No.  Special copay programs, such as those for Prilosec OTC, OTC nicotine patches and for generic cholesterol-lowering medications, will remain unchanged.

12. Will there be any changes in the cost of diabetic supplies?
No.  Copays for diabetic supplies will continue to be $10 for generic and preferred brands, and $25 for non-preferred brands. Members who use insulin may receive up to 150 testing strips every month, and those who do not use insulin may receive up to 150 testing strips every 3 months.  If members use larger quantities, they may obtain additional testing strips under their medical benefit, as before.

13. Why was I paying less than my copay for some drugs since July and now the cost has increased to the copay?
On July 1, 2009 there was a change in the Plan benefits to allow certain drugs that may cost less than the copay to be charged at the lower rate. Therefore, you may have been paying less than your copay for certain generic drugs since that time. Due to a Legislative update that benefit will change effective 10/1/09 so that your charge for these medications may change. You will never pay more than your stated copay for a medication. Be sure to shop around for your medications since prices may vary at different pharmacies. Click here to find out more about available Low Cost Generic Programs

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