Closed Rx Benefits

Your closed prescription benefit is designed to be simple to use, keep your out-of-pocket expense low and control costs by pointing both you and your healthcare provider to clinically sound and cost-effective medications. To do this, the benefit breaks prescription medications into two categories, or tiers:

• Generic
• Formulary brand-name

You have coverage for both categories. What you pay - your copay or coinsurance - depends on which medication (or tier) you and your doctor choose. Generics cost the least, and non-formulary medications are not covered in this prescription benefit design. You would be responsible for the full cost of the medication, if you and your doctor decide to use a medication not on the Preferred Medication List (PML).

Let’s look at a couple of examples of what a closed benefit could look like:

Example 1:
$5 retail pharmacy copay for generic medications (30 to 34-day supply)
$25 retail pharmacy copay for brand-name formulary medications (30 to 34-day supply)

Example 2:
$10 retail pharmacy copay for generic medications (30 to 34-day supply)
20% retail pharmacy coinsurance for brand-name formulary medications (30 to 34-day supply)

Many conditions can be treated with a variety of medications-some generic, some brand-name. Our committee of practicing physicians and medication specialists carefully study how clinically effective-and how cost-effective—all medications are. If the same result can be achieved for either $15 or $100 per month, which way would you go?

How Do You Know Which Tier Your Medication Belongs To?
The Preferred Medication List/Formulary is a guide to which medications are covered and at what copay/coinurance level. Generic medications are in the first tier (lowest copay), brand name medications in the second and nonformulary products are at your own expense.

For a complete list of covered generic and brand-name medications, take a look at our Preferred Medication List/Formulary.

Any drug not on the list is considered non-formulary. If you've been prescribed a medication that's not on the PML, you may be able to offer your doctor this list of alternatives to nonformulary medications. If your doctor prescribed a brand-name or nonformulary medication, you can ask the pharmacist for the generic equivalent. Unless your doctor specifically prescribed only the brand-name medication, you can receive a generic equivalent and pay the lower copay.

Also, a small number of medications on the PML require that your doctor obtain prior authorization before we can cover them.

Filling Prescriptions
First of all, make sure you visit a participating pharmacy or use one of the participating mail-order pharmacies. At the pharmacy, simply present your member card with your prescription - your pharmacist will know which tier your medication is on and charge the applicable copay.