Why should I use a generic over a brand name drug?
A generic drug is chemically identical to its brand name counterpart. The FDA goes through the same approval process for generic medication as it does for brand name drugs. The generic drug manufacturer has to prove that the drug is the "bioequivalent" of the brand name drug and that it provides the same results. Generic drugs are usually sold at a price 20-80% less than the brand name product. On most plans, you have the choice to continue to use a brand name medication but your copayment will reflect a greater share of the cost for the brand name.
What is a Preferred Drug List?
Your group may or may not have a Preferred Drug List as part of its plan. Preferred drugs are determined through clinical study to be the most effective for the most number of patients. If more effective or safer drugs that are reasonably priced appear on the market, they may be added to the list. By using a generic or a preferred drug, you may save money over the brand name drug and continue to receive the same high quality of care.
How are drugs covered in an open Preferred Drug List?
A health plan with an open Preferred Drug List offers members coverage for drugs on the Preferred Drug List as well as drugs that are not. Publication of the Preferred Drug List encourages use of listed drugs but prescribing from the Preferred Drug List is not aggressively enforced. PAI processes claims according to each group's plan. Some drugs on the Preferred Drug List may not be covered by your health plan. An example for certain plans would be oral contraceptives or fertility medications.
How are drugs covered in a tiered copayment plan?
In a tiered copayment plan, drugs are assigned to different (usually two or three) copay tiers based on cost-sharing or clinical considerations or both. Typically you can reduce your out-of-pocket costs when using drugs that fall into tier 1 and 2 (generic drugs or preferred brand-name drugs).
How are drugs selected to be on the Preferred Drug List?
In-house clinicians and independent panels of physicians evaluate drugs based on objective clinical criteria. The Preferred Drug List is determined by the independent members of Pharmacy and Therapeutics, or P&T, Committee. In the clinical review process, a drug is assessed for its safety and efficacy. A drug is compared with alternative products in its therapeutic class, and the relative benefits are determined.
What if my drug is not listed on the Preferred Drug List?
The Preferred Drug List includes drugs by generic name. If the brand name you seek is not shown, it is possible the drug is included but is listed under a different brand or the product is not a preferred drug. You may want to bring your Preferred Drug List with you when you visit your physician. Your physician may then choose to select a drug from the Preferred Drug List for you.
What if my doctor doesn't agree that an alternative drug is appropriate in place of the drug I am currently taking?
Your doctor should determine the treatment plan that is most appropriate for your condition. In some cases, this may mean you will stay on a drug that has a higher copayment.
How do I know what I will pay for a prescription?
Refer to your benefit summary provided by your health plan to determine your copayment for the specific drug your doctor prescribed. Most pharmacists also have access to your plan copayment policy.
What if I am currently taking a prescription for a drug that is not on the Preferred Drug List?
If you are now taking a brand name medication not on the Preferred Drug List, you may choose to continue the drug at a higher copayment or you may ask your physician to change your medication to a generic or preferred drug from the list. Either you or your pharmacist can arrange this with a simple phone call to your physician.
What can I do to reduce the amount that I have to pay when filling my prescriptions?
- Choose generic drugs whenever possible.
- Carry your Preferred Drug List with you when you see your doctors so they may prescribe from it whenever possible.
- Use the mail order pharmacy services whenever possible. Some plans may require the use of mail order for refill prescriptions. Mail order is easy, convenient, and provides a 90-day supply of most medications.