Proposed Empire Plan Prescription Drug Benefits

Frequently Asked Questions

Q:        How will the proposed prescription drug benefits work?

A:         Express Scripts, the current prescription drug manager, will continue to manage the drug plan. Instead of two benefit levels for generic and brand name drugs, there will be three: generic, preferred brand name and non-preferred brand name. Generic drugs will have the lowest copays. Brand name drugs will be placed in the preferred or non-preferred category depending on their clinical effectiveness, whether or not a generic equivalent is available, safety and cost.

Q:        What are the proposed copays?

Q:        Why were these changes to the prescription drug benefit proposed?

A:         Prescription drug prices have increased dramatically over the last five years and show no signs of slowing down. These changes in the prescription benefit are intended to help reduce the growth rate for drug costs in the Empire Plan in two ways.  First, by increasing the copay, plan costs are reduced and premium costs will be lower.  Second, through the use of "incentives" (lower co-pays) for preferred drugs, enrollees are encouraged to discuss with their doctors the use of lower cost drugs. These types of prescription plans are very common; in fact, 11 of the 13 HMOs offered to State employees already have them. The other two HMOs require the member to pay the full cost of drugs that are not on the preferred drug list.

Q:        Are doctors and pharmacists aware of which drugs are on the preferred list?

A:         Printed copies of the preferred drug list are generally distributed to doctors and enrollees, and an online preferred drug list is available 24 hours/7 days a week to doctors, pharmacists and enrollees.

Q:        How can I determine if a drug is on the preferred list?

A:         To determine if a drug is on the preferred list, members should call Express Scripts at 1-800-964-1888.  Customer service representatives are prepared to respond to these inquiries.   

Q:        Of the prescription drugs that are currently covered, which drugs would be excluded from the proposed drug benefit?

A:         None, all are included in the proposed drug benefit; the only change is that you may have to pay a higher copay for certain drugs.

Q:        I’m concerned that the brand name drugs I take will all be in the non-preferred category with the highest copay.

A:         An analysis of the 25 most frequently prescribed drugs used by PS&T unit Empire Plan enrollees showed that 23 were in the preferred category, one was in the non-preferred category, and one had converted to

over-the-counter and therefore was no longer available as a prescription. The majority of drugs in the non-preferred category are brand name drugs for which a generic equivalent has been approved by the FDA. Currently, the Empire Plan has a mandatory generic substitution requirement, which requires the enrollee to pay the difference in cost between the brand name and generic drug, in addition to the copay. That requirement will continue. (Note: the PS&T data on most frequently prescribed drugs were aggregate (group) data with no information that could be used to identify individual enrollees.) 

Q:        I’m concerned that all the expensive, most effective drugs will not be on the preferred drug list.

A:         Drugs generally are placed in the non-preferred category only when there is a preferred drug that offers the same therapeutic benefit or there is an approved generic.  Certainly cost is a factor, but it is not the primary consideration.  For example, the FDA recently approved a new asthma drug called Xolair.  It's among the first genetically engineered drugs to be approved.  While the benefits can be enormous for people suffering from allergic asthma, so is the cost: between $10,000 - $24,000/year depending on the dosage.  Despite the high price, when the drug was approved it was placed on the preferred drug list.

Q:        How will I know what my copay(s) will be for different drugs?

A:         The copay you are responsible for when filling a prescription will depend on the drug you are receiving, the quantity or supply of the drug, and whether you are using a retail pharmacy or the mail order pharmacy. You can check the status of a drug by calling Express Scripts toll-free at 1-800-964-1888 with the name and dosage of the drug.

Q:        How often are changes made to the preferred drug list?

A:         New drugs recently approved by the FDA are added on a quarterly basis. Other than when a generic equivalent becomes available, brand name drugs that change from the preferred to non-preferred category are removed from the preferred drug list on January 1st of each year. When a generic equivalent for a brand name drug becomes available, the brand name drug is immediately moved to the non-preferred category.

Q:        How are drugs placed on the preferred drug list and who makes that decision?

A:         The Express Scripts National Pharmacy and Therapeutics (P&T) Committee, composed of non-employee physician members from a broad range of medical specialties, determines whether a drug should be included on the preferred drug list. When deciding which drugs to approve, P&T committee members consider studies of each drug's effectiveness, safety, market share and cost, compared with other drugs in the same category.

Q:        If my mandatory generic appeal for a brand name drug has been approved, what will my copay be?

A:         If your doctor feels it is medically necessary for you to have a brand name drug (that has a generic equivalent), you can appeal the Mandatory Generic Substitution requirement. If your appeal is granted, you can fill your prescription for the brand name drug at a retail or the mail order pharmacy. Since brand name drugs with a generic equivalent are not included on the preferred drug list, you will be responsible for the non-preferred drug copayment amount. 

Q:        Can I still get up to a 90-days supply at my local retail pharmacy? Is a mail order benefit still available?

A:         You may still get up to a 90-days supply at your local retail pharmacy, or you may get up to a 90-days supply through the mail order pharmacy. See the chart above for proposed copays at these locations.

Q:        I’m concerned that my medication may be affected by temperature extremes if it sits in my mailbox all day while I’m at work.

A:         There are several ways to address this common concern. Any drug that must be refrigerated will be packed in dry ice before it is shipped. During the winter months, if there is a risk that a liquid may freeze, you can arrange for an alternate delivery address including your worksite or a neighbor’s home. Enrollees in the Capital District may go to the Express Scripts mail service center in Troy and pick up prescriptions there. If you have questions about a drug’s sensitivity to temperature changes, you may speak to a pharmacist at Express Scripts by calling 1-800-964-1888.   

Q:        Are brand name drugs used to treat certain medical conditions automatically placed on the preferred list?

A:         Brand name drugs, with no generic equivalents, used to treat HIV/AIDS, cancer and anti-rejection drugs following an organ transplant are always placed on the preferred list.

9/2/04