In the January issue of NewsfromBlue, we introduced the required generic substitution benefit (effective April 1), encouraging members to choose lower cost generic drugs in place of high cost brand medications. To help clarify how this affects the member’s health and/or the pharmacy deductible and out-of-pocket maximum, please keep these key points in mind:

• If the member chooses to fill a prescription with a brand name drug when there is a generic available, they will pay more than they would for the generic drug.
• Depending on the type of drug, this could represent a significant cost difference. As a result, members may think they’ve satisfied their deductible and/or out-of-pocket responsibility sooner than what is correct.
  • Non-HSA Plan with Rx Deductible: If a member chooses to fill a brand medication when a generic equivalent is available, ONLY the cost of the generic equivalent will apply towards the member’s deductible.
  • HSA Plan with Integrated Rx: For members who are enrolled in a HSA compatible plan with Integrated Rx, the cost difference between the generic and brand will not apply towards the member’s deductible or out-of-pocket maximum. If a member chooses to fill a brand medication when a generic equivalent is available, ONLY the cost of the generic equivalent will apply towards the member’s deductible and/or out of pocket maximum.
• Mandatory generic substitution does not apply if the prescriber requests the brand drug. In order for the member to fill the brand name prescription without paying the cost difference, the prescribing physician must indicate “Medically Necessary” on the prescription.

This will be a standard benefit for all existing fully insured groups upon their renewal, starting with groups that renew on April 1, 2009. Administrative Services Only (ASO) groups who would like to add this benefit upon renewal may do so. This will be a standard benefit for all new groups (ASO and fully insured) that are sold on or after April 1, 2009. Fully insured groups (500+) and ASO groups (any size) can opt out of the standard benefit if they prefer.

More than 94% of our members already use generic equivalents and the impact of this new pharmacy benefit will be reflected in the new rates upon the groups’ renewal.

Please review these Frequently Asked Questions for more information.