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Why did my plan switch to a new prescription benefit?
In the past, having to pay a flat 20% for each prescription independent of drug cost was a major disadvantage to patients with serious illness who incurred very high out-of pocket costs. In addition, the new plan allows the health plan to control cost, which also means that your insurance premiums will be less than they would be otherwise.
How does the new plan benefit me?
The new plan has a fixed co-payment structure, which means that you will only be required to pay a fixed amount depending on the tier in which a drug is placed. For example, you will only pay up to $35 for a 30-day supply of a non-preferred brand drug that would have cost you a lot more. This would have cost you $600 dollars out of pocket in the previous plan. In addition, you will know the amount you will pay in advance.
I have serious health condition and was paying a lot out of pocket previously. Will the new plan benefit me?
Yes. The new plan greatly benefits those members with serious illness who were previously paying large amounts out of pocket for their medications and who now will pay no more than $35 per 30 day supply. Some illnesses which fall in this category would include: 1) cancer 2) organ transplant 3) HIV 4) multiple sclerosis, and a number of other conditions.
I was previously paying very little out of pocket for my maintenance medications. Will the new plan benefit me?
It depends on how much you were paying out of pocket and which tier your medications falls under. If they are available as generic drugs, and you order your prescription through the mail, your cost should remain low. If you decide to fill the precription at a retail pharmacy and insist on the brand-name drug, you probably will pay more under the new plan than you paid previously.
In the new plan, you may pay a little more for a 1-month supply of a cheap drug than what you were paying previously, but you will pay a lot less for some of the more expensive brand-name drugs (some common brand-name drugs can cost as much as $200-$300 for a 30-day supply). Also, if your physicians prescribe an equivalent generic medication, you will decrease your cost substantially.
Can you provide a few concrete examples of how the new plan and the old plan compare in terms of how much I might have to pay out of pocket for a few commonly prescribed drugs?
The chart below compares the co-payment amount under the new design to the previous 20% coinsurance amount based on a 30-day supply of select drugs:
Current Co-payment Amount
Previous Coinsurance Amount
Wellbutrin XL 150mg
Advair discus 250-5
I heard that the new plan allows me to obtain a prescription for certain OTC medications at no cost. Is that true?
The new plan also allows you to fill 3 over-the-counter drugs by prescription at zero cost to you. Previously, this option was not available. These drugs are Prilosec, Claritin and Claritin-D. All 3 are considered good therapeutic alternatives to expensive brand-name prescription drugs. In fact, all 3 of these drugs used to be available by prescription until recently.
What is a drug formulary?
A formulary is a list of medications that are eligible for coverage under the Pharmacy Benefit Program. Your physician can use the formulary for your healthcare needs while helping you maximize your prescription drug benefit. The formulary applies to medications that are dispensed in both retail and mail order pharmacies.
Who develops the formulary?
The Johns Hopkins Healthcare (JHHC) Pharmacy and Therapeutics Committee will be responsible for development and maintenance of the drug formulary. This committee comprises of Johns Hopkins faculty physicians, community physicians and pharmacists.
Are generic drugs of equal quality to brand drugs?
Generic drugs are a safe and effective alternative to help reduce prescription drug cost. Generic drugs have the same active ingredients as brand-name drugs, and the FDA requires all drug manufacturers to meet the same production process and control standards. For more information about generic drugs, view the FDA Office of Generic Drugs Web site at http://www.fda.gov/cder/ogd/index.htm
What is the difference between a Preferred drug and a Non-Preferred drug?
A preferred drug is a medication that has been clinically reviewed and approved by the Pharmacy and Therapeutics Committee. This medication has been included based on its proven clinical and cost effectiveness.
A non-preferred drug is a medication that has been determined to have an alternative drug available that is clinically equivalent.
If I am taking a brand name drug when a generic equivalent is available, at what co-payment level will this drug be available?
Generic drugs on the formulary will be subject to tier one co-payment, while their brand name equivalents will be subject to third-tier co-payment provided your doctor specifies “dispense as written’ (DAW) on your prescription. If your doctor does not specify DAW and you request a brand name drug, you will pay the difference in cost between the generic and brand in addition to the applicable co-pay.
Why are there different co-payments for different drugs?
The cost of drugs varies widely, even though several different medications may be used to treat the same condition. Generic drugs offer the most savings and, therefore, have the lowest co-payment.
What do I do if my physician prescribes a medication that is listed as “Non-Preferred Brand”?
If your doctor believes that you must have a Non-Preferred Brand, the prescription will be filled at the Non-Preferred Brand (third tier) co-payment level.
Under the previous plan, members were responsible for 20% of the drug's cost. Since the cost varies by drug, it was almost impossible to determine how much you would pay without taking your prescription to a pharmacy. Also, the 20% coinsurance could range from $4 for a drug that cost $20, to $600 for a drug that cost $3,000.
Under the new plan, you will only be required to pay a fixed amount depending on the tier in which a drug is placed, i.e. you will only pay up to maximum of $35 for up to a 30-day supply of a drug that may cost $3,000. In addition, you will now exactly how much you will pay in advance.
Does the prescription plan cover Over-the-Counter (OTC) Drugs?
The old plan did not allow members to obtain a prescription for medications that are available “over-the-counter” (“OTC”). A drug or medication is considered to be OTC if it can be obtained without a prescription, regardless of whether or not your doctor gives you a prescription for it.
In the new plan, you may request a precription for Prilosec OTC, Claritin OTC and Claritin D OTC. Your doctor must write a prescription for these drugs which you will need to show the pharmacist at the time of purchase. There is no co-pay when you obtain Prilosec OTC, Claritin OTC and Claritin D OTC with a doctor's prescription.
How do I determine which co-payment level my medications fall under?
You may obtain this information by logging onto the Caremark website at https://www.caremark.com (please note, registration is required in order to obtain information specific to your plan)
What is the advantage to using mail-order for maintenance medications?
The advantage to using mail-order instead of retail is that members will only pay 2 co-pays for a 90-day supply instead of 3 co-pays. The corresponding member co-pay will be determined based on the drug tier. For example, a 90-day supply of a preferred brand drug at the retail pharmacy = $60 ($20 for each 30-day supply). Via mail-order, a 90-day supply of the same drug = $40, thereby saving 1 co-pay every 90 days.
What is the process for using mail-order for maintenance medications?
To use mail order, please go to https://www.caremark.com, register and follow the directions provided. You will need to complete and mail a form accompanied by a prescription from your physician for a 90-day supply of the medications you plan to order this way.