PRESCRIPTION
UPDATE
UNDERSTANDING THE PRESCRIPTION DRUG PLAN
We have had a number of phone calls regarding the changes to the prescription drug portion of the Empire Plan retiree health insurance. Many of these calls were generated by a letter that was sent by the pharmacy benefit manager, Express Scripts®, to Empire Plan enrollees who are using a prescription drug that will be considered as a “non-preferred brand name” under the new benefit design. Because there is so much confusion among our members on this subject, we have put together the following information.
In the latest round of collective bargaining with all of the unionized groups, NYS negotiated significant changes to the Empire Plan. The medical coverage is virtually identical for all unionized bargaining units and, as we have described elsewhere, virtually the same also for the retirees (although the retiree coverage is NOT negotiable). For all concerned parties, the changes are being driven by the general cost of health care and the rapid rise in those costs. NYS spends around $1.2 Billion on employee prescription drug coverage so there is a significant incentive to reduce the total cost and certainly to reduce the rate of yearly increase.
Given this scenario, it is in the interest of both the State and the employees/retirees to do whatever is reasonable to control or reduce health care costs. For the state, it is important to its efforts to come up with a balanced budget. For the retirees, it is important to their ability to continue to receive health care coverage. So far, there have been no serious efforts made to reduce our health care coverage, either out-of-hand or by pushing those eligible retirees onto Medicare alone. Public comments by the Governor suggest that he is neither planning to do this nor wants to do it, which is very good. But the political and fiscal necessities are such that costs must be contained. One way to do that is by monitoring and controlling prescription drug outlays.
The prescription drug changes have resulted in a three tiered classification for all FDA-approved drugs: generic, preferred brand-name, and non-preferred brand-name. Generic drugs are ones which no longer have, or never had, patent protection and are generally referred to by their chemical names. Brand-name drugs may still have patent protection so they can only be produced by the creating pharmaceutical company or those companies licensed by the creating company. If a patent is still in effect, manufacturing a generic is prohibited by the patent laws. Under the umbrella of brand-name drugs, however, the pharmacy benefits manager has further divided the available drugs into preferred and non-preferred types. Drugs are generally placed on the non-preferred list only when there is a preferred drug that offers the same therapeutic benefit or there is an approved generic available. When deciding which drugs should be on the preferred list,
Express Scripts® looks at a drug’s effectiveness, safety, market share, and cost as compared with other drugs used to treat the same condition. Drugs deemed experimental or whose effectiveness has not been proven or drugs for which there is serious scientific doubt about their actual effectiveness or even safety, are not covered at all.
Because generic drugs are so much less expensive than brand-name, using generics as often as possible certainly makes good sense. However, while the active ingredient in a generic is identical to the active ingredient in the equivalent brand-name, there may be, and often are, differences in the inert ingredients. Consequently, it sometimes happens that a particular generic drug may not work as well as a brand-name, for a particular individual, because of side effects or some other peculiarity of the different inert ingredient(s). This then can cause the physician to prescribe a brand-name drug instead of a generic. There are times, also, when only a brand-name drug is available.
As you no doubt realize by now, the cost to us escalates dramatically as we go from generic to brand-name and from preferred to non-preferred. The significant change is for maintenance drugs (long term usage for a chronic condition); co-payments for prescriptions for short-term use, 30 days or less, do not change unless the drug is a non-preferred drug. For those of your maintenance prescriptions which are generic, there is little else to do. A generic prescription filled through mail-order is still $5 for 90 days supply; if you want to have that same prescription filled at your neighborhood pharmacy, the co-pay is $10. For brand-name drugs, the going gets a little pricier. If the maintenance brand-name drug is preferred, the cost goes up considerably whether by mail-order or by local retail and if it is non-preferred, it really goes up. In addition to the difference in co-pays for the different classifications, there may be an additional charge equal to the difference in cost between the brand-name and generic and this can be quite high. For example, if a non-preferred, brand-name drug with a generic equivalent is the only thing for you and the cost difference between it and the generic is $100, you will be required to pay the co-pay of $55/$60 plus the price difference of $100 for a total of $155/$160 (before you totally panic, see below). What then can we do to keep our own costs within our individual budgets?
Probably the first thing would be to list what drugs you currently use and check them against the generic/brand-name/preferred/non-preferred list which is available for review from the Department of Civil Service web-site
www.cs.state.ny.us, clicking on ‘You Should Know’ or by calling Express Scripts® at 1-800-964-1888. Next would be the determination as to which of these drugs are for one time use and which are for long-term use.
Once you have a good handle on what drugs you use, it may be time for a chat with your physician. For all of your brand-name maintenance prescriptions, ask your doctor if he can prescribe a generic equivalent. This applies to all brand-name drugs, preferred and non-preferred. As soon as a generic drug comes on the market, the brand-name drug that it can substitute for automatically becomes non-preferred, if it is not already there. Consequently there are many drugs on the non-preferred list that have generic equivalents. For any non-preferred drugs without a generic equivalent, ask your physician if there is a preferred brand-name. You will probably have to bring in the drug classification chart so that your doctor can determine the classification for the drug in question.
Obviously, if it is possible to switch from a non-preferred to a preferred or to a generic, that is the way to go. However, if your physician states that you must take a non-preferred brand-name drug that has a generic equivalent, there is an appeal process whereby your physician can articulate his reasoning for using the brand-name instead of the generic. If the appeal is successful, you will still have to pay the non-preferred co-pay but you will not be hit with the price difference between the cost of the non-preferred and the cost of the generic.
If the appeal fails, or if your financial situation is sufficiently grave, the next step might be to ask your physician for sales samples. Most drug companies and their sales people provide samples to physicians and if your physician has some available perhaps he will provide them to you. Usually this is only a short term fix but some physicians use these samples for their more financially strapped patients, on a long term basis and if they have a continuing supply of the samples. You may also want to talk to your pharmacist; s/he may be aware of other ways to obtain lower cost prescriptions, either through private help or local/state government programs. Other suggestions can be found at
www.institutedc.org/top17.htm.
If you are dealing with Express Scripts®, they have a program called Rx OutreachSM which can provide some drugs at a reduced co-pay to people who meet certain income limits. Lastly, there is the web-site
www.helpingpatients.org which displays data about the various low-income assistance programs of many pharmaceutical companies. There is an application that must be completed which requests financial information. The income limits are usually such that only those who have very low incomes will qualify and the plans are often restricted to those who have no drug coverage at all but it doesn’t hurt to check it out.
Organization
Mission
Statement
Who We Are
Statewide
Officers
Chapter Presidents
Communication
Retirees In Action
President's
Report
Newsletter
Health Insurance
Update
'05
Status of Health Insurance
Constitutional Convention
Prescription Update
Health care letters - Legis.
Assembly Member list
Senate Member list
Healthcare Prot. memo
Healthcare bill status
Action
Health Care Protection bill
Campaign Involvement
Campaign Activity 2006
COPE
Political Action
PAC Lobbying
PAC Legislation
PEF PAC
Retirement Awareness
Pre-Retirement
Prospective Retiree Letter
Dental Choices
Pre Retirement Planning
NYSLRS
Post-Retirement
About
PEF Retirees
Joining PEF Retirees
Retirees
Application
Form
Pension Check Deduction
Benefits
Benefit Summary
Federal Retirement Benefits
NYS Retirement Benefits
PEF Retirement Dental
Other
Contact
Information
Other
Retirement Benefits
Retirees Questions?
or call the Retirees at 800-342-4306 Ext. 289.
Register
here
for the PEF Member Network.