Open Rx Benefits

Drug developments improve our lives - but they come with a price. Providing choice and enabling effective medication therapy while controlling costs requires teamwork - among you, your doctor and pharmacist, and your health plan. With an open prescription benefit, the price you pay is the same regardless of whether the medication is on the Preferred Medication List/Formulary (PML) or not.

Here's what you need to know:

• An open prescription benefit gives you choice over which medications you use but does not attempt to balance costs or reduce trend. The benefit may or may not break prescription medications into categories, or tiers.
  • Generic
  • Brand-name
  
  
• You have coverage for both categories. Depending on your specific plan you might pay one amount regardless of the medication being a generic or brand (example 1), or there may be some differential between generic and brand-name medication (example 2). The total cost of generics is the least in the second example.

Let’s look at two examples of an open prescription benefit:

Example 1:
$20 retail pharmacy copay for any medication, generic or brand (30 to 34-day supply)

Example 2:
$7 retail pharmacy copay for generic medications (30 to 34-day supply)
$15 retail pharmacy copay for brand-name medications (30 to 34-day supply)

How Do You Know Which Tier Your Medication Belongs To?
While you won’t be required to chose a drug from the Preferred Medication List/Formulary (PML) it still should be used as a guide to which medications are both clinically sound and cost-effective. In the second example above, generic medications are in the first tier (lowest copay), while all brand name medications are in the second (highest copay).

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

Any drug not on the list is considered non-formulary in most benefit designs. If you've been prescribed a medication that is 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 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, regardless of your benefit design, 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.