| 2007 PEBB Prescription Drug Plan Design |
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| RX Plan Design Overview |
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The Board designed the prescription drug benefit in the PPO plans to encourage members and providers to consider whether the medicine being prescribed is equally effective as others and at less cost.
Members in the full-time PPO plans have a co-pay of only $5 when using an available generic medication that is equally as effective as a drug on the plan’s lists of preferred-brand medications. Members who select a preferred-brand medication have more responsibility for the cost, paying $15. Members who choose a brand drug not on the list of preferred brands – a non-preferred brand – have an even greater portion of the cost as their responsibility.
How does the non-preferred brand drug payment work in the PPO plans?
There are two types of non-preferred brand drugs – single-source and multisource. A single-source brand drug has therapeutic alternatives available – drugs that treat the problem effectively but that don’t contain the same active ingredients as the preferred-brand. A multisource brand drug has a generic equivalent available with the same active ingredients as the brand drug. Payment works differently for each.
Non-preferred, single-source brand drug:
You would pay the greater of $50 or 50% of the cost of the drug. However, your co-pay will never be higher than the actual cost of the drug.
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Example of Multisource Non-preferred Brand Drug Co-pay Calculation
The generic equivalent drug costs $15, and the multisource non-preferred-brand drug costs $60.
For a non-preferred multisource brand drug, you pay as follows:
- The greater of a $50 co-payment or 50% of the cost of the brand-name drug, plus
- the difference between the generic drug cost and the brand-name drug cost, but
- no more than the cost of the brand-name drug.
To calculate the co-pay, consider a brand name drug that costs $60 and a generic that costs $15:
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50% of the cost of the brand-name drug is $30. $50 is greater than that; enter $50.
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$50
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2.
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The difference in cost between generic and brand is $45. Add $45 to $50.
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+$45
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The total, $95, is higher than the actual cost of the brand drug, $60.
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= $95
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3.
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You will never pay more than the actual cost of the drug. So, your copay is $60.
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$60
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Exception processes
Some physicians may still prescribe a non-preferred (non-formulary) brand drug for medical reasons. For example:
- You did not have a good outcome with an alternative drug.
- You are allergic to or can’t tolerate an alternative drug.
For these reasons, each of PEBB’s medical plans has an exception process. If your situation meets the plan’s requirements, you may be able to purchase the drug at the preferred-brand cost.
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| Full-time Medical Plans |
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2007 PEBB Prescription Drug Coverage in Full-time Medical Plans
Select the plan's name to see the plan's exceptions process for non-formulary drugs
Coverage
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Tier 1 HMO
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Tier 2 PPO1
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Tier 3 OON1
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Retail supply
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30-day
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30-day
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30-day
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30-day
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34-day
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34-day
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34-day
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Pharmacies
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Kaiser Only
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Kaiser Only
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MedImpact
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MedImpact
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Participating Pharmacies Only
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Participating Pharmacies Only
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Generic
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$1
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$5
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$20
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$20
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$5
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$5
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$5
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Brand
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$15
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$15
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$20, plus2
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$20, plus2
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$15
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$15
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$15
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Non-preferred Brand
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Nonformulary
not covered
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Nonformulary
not covered
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$20, plus2
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$20, plus2
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>$50 or 50%, plus3
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>$50 or 50%, plus3
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>$50 or 50%, plus3
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90-day Mail supply
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Generic
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$1
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$10
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$104
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$104
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$12.50
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$12.50
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$12.50
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Brand
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$15
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$30
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$304
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$304
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$37.50
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$37.50
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$37.50
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Non-preferred Brand
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Nonformulary not covered
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Nonformulary
Not Covered
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Nonformulary
Not Covered
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Nonformulary
Not Covered
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>$125 or 50%, plus3
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>$125 or 50%, plus3
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>$125 or 50%, plus3
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1 OON is “out of network.” Pharmacy coverage for tiers 2 and 3 through MedImpact pharmacies. May submit non-Kaiser prescription orders to Kaiser’s mail-order pharmacy if drug is in stock and in Kaiser formulary.
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2Plus the difference between generic and brand.
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3Plus the difference between generic and brand for multisource brands. Multisource brand - a brand where there is an exact generic equivalent available.
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4 May submit to Kaiser mail-order pharmacy if drug is in stock and on formulary.
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| Part-time & Retiree Plans |
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2007 PEBB Prescription Drug Coverage in Part-time and Retiree Medical Plans
Select the plan's name to see the plan's exceptions process for non-formulary drugs
Coverage
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Tier 1 HMO
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Tier 2 PPO
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Tier 3 OON
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Retail Supply
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30-day
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30-day
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30-day
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30-day
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34-day
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34-day
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34-day
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Generic
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$10
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$10
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$30 1
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$30 1
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$10
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$10
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$10
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Brand
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$25
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$25
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$30 + 1,2
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$30 + 1,2
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20%
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20%
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20%
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Non-preferred
Brand
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Nonformulary not covered
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Nonformulary
Not Covered
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Nonformulary
Not Covered
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Nonformulary
Not Covered
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>$50 or 50% + 3
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>$50 or 50% + 3
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>$50 or 50% + 3
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90-day Mail Supply
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Generic
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$20
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$20
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$20 4
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$20 4
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$25
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$25
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$25
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Brand
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$50
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$50
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$50 + 4
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$50 + 4
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$62.50
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$62.50
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$62.50
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Non-preferred brand
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Nonformulary not covered
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Nonformulary
Not Covered
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Nonformulary
Not Covered
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Nonformulary
Not Covered
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$125 + 3
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$125 + 3
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$125 + 3
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1 OON is “out of network.” Pharmacy coverage for tiers 2 and 3 through MedImpact pharmacies. May submit non-Kaiser prescription orders to Kaiser’s mail-order pharmacy if drug is in stock and in Kaiser formulary.
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2Plus the difference between generic and brand.
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3Plus the difference between generic and brand for multisource brands. Multisource brand
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4 May submit to Kaiser mail-order pharmacy if drug is in stock and on formulary.
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