* Classification of a particular drug as generic is based on generic
product availability and cost, compared to the reference brand.
Occasionally, a product which is labeled by the pharmacy as a generic
will have similar cost to the brand product. In such cases, a Tier 2
cost share may apply.
How to Get the Most from Your Prescription Drug Benefit
|
|
At your health care
provider's office: |
- Ask
your doctor or practitioner to prescribe a generic drug when
available and appropriate.
-
If a
generic is not available and appropriate, ask your doctor or
practitioner to consider prescribing a preferred brand-name drug
from the Preferred Drug List, when appropriate.
|
|
At the pharmacy: |
- Ask
your pharmacist to fill
your prescription with a generic drug when allowed by the
prescription
|
About Generic and Brand-Name Drugs
 |
Brand-name drugs are sold under a
manufacturer's trade name. Generic drugs are sold under the chemical
names.
Both brand-name drugs and their generic equivalents are regulated by
the Food and Drug Administration (FDA) to help ensure the same level
of quality, strength and purity. However, not all brand-name drugs
have a generic equivalent.
Generic drugs are an excellent value. They generally cost less because
they are created without the development, advertising and sales
expense of brand-name drugs. Additionally, competition among the
makers of generic products lowers price.
We encourage you to use a generic drug whenever one is available and
allowed by your doctor or practitioner. Generic drugs can save you
money, because they are covered at the Tier 1 benefit level.
To be sure you pay the lowest possible out-of-pocket costs, ask your
doctor or practitioner to indicate "substitution permitted" on your
prescription. Then ask the pharmacist to use a generic to fill the
prescription.
If your prescription does not have an available generic, you will be
given the brand-name drug. In some cases, your doctor or practitioner
may want you to receive the
brand-name drug even though a generic is available. In that case, you
will be responsible to pay for the difference between the cost of the
brand-name drug and generic in addition to the copay. |
If You Get a Brand-Name Drug When a Generic is Available |
There may be situations when you or your
doctor or practitioner selects a brand-name drug even when a generic
is available.
If you request a brand-name drug when a generic equivalent is
available and allowed by your doctor or practitioner, you will be
responsible for paying the difference in price between the cost of the
generic and the allowable charge for the brand-name drug, and benefits
will be provided at the Tier 2 or Tier 3 level, depending on which
tier the drugs falls into.
If your doctor or practitioner requires a brand-name drug when a
generic equivalent is available, benefits will be provided at the Tier
2 or Tier 3 level, depending on which tier the drugs falls into. |
Preferred and Non-Preferred Brand-Name Drugs
|
The list of commonly prescribed drugs
identifies some drugs as Tier 2 preferred
brand-name drugs and some as Tier 3 nonpreferred brand-name drugs.
LifeWise Health Plan's Pharmacy and Therapeutics Committee makes
decisions about which brand-name drugs are preferred and nonpreferred.
This group includes doctors, practitioners and pharmacists from the
community. The committee uses current medical studies and research to
choose safe and effective drugs.
The committee reviews and updates the
Preferred Drug List regularly by adding the latest safe and
effective drugs, and removing those that are no longer considered safe
and effective for which better alternatives are now available.
The committee recommends that doctors and practitioners prescribe
preferred brand-name drugs when a generic is not available. These
preferred brand-name drugs are covered with a Tier 2 benefit.
Brand-name drugs not listed on the
Preferred Drug List are considered Tier 3 non-preferred drugs and
have the highest cost. These drugs may be non-preferred for a variety
of reasons: |
- There are generic equivalents available.
- There are preferred brand-name
alternatives available.
- LifeWise
Health Plan's Pharmacy and Therapeutics Committee has concerns about
their safety or effectiveness.
|
|
Your doctor or practitioner has been
provided a copy of the
Preferred Drug List to use when writing a prescription. |
Important Items To Note
|
The
Preferred Drug List does not include non-preferred brand-name
drugs. Any brand-name drugs not on the list are considered
non-preferred and are covered with the Tier 3 benefit level.
|
|
Please note that
certain types of drugs are not covered by your program. This includes
drugs for treatment of mental or psychiatric conditions, obesity,
weight control, drugs for cosmetic purposes, and drugs to treat sexual
dysfunction or infertility. Refer to your contract for a complete
description of the drug categories which are excluded. |
How to Know if Your Drug is Tier 1, 2 or 3
|
- Use this
link to the Preferred Drug List - drugs are listed in
alphabetical order or by drug category and have the tier listed beside them.
- Ask your pharmacist - pharmacy computer
systems have the most up-to-date version of the drug list (at the
point of purchase).
- Call LifeWise Health Plan's Customer
Service - the toll-free number is
1-888-836-6135. They will be available to help you with any
questions you may have about your prescription drug benefit.
|
How to Get Your Prescription Filled
|
|
To get the most from your pharmacy
benefit, you should have your prescriptions filled at a participating
pharmacy. |
Filling Your Prescriptions at a Local Pharmacy or
When Traveling |
LifeWise Health Plan uses a network of
more than 60,000 retail pharmacies. Most pharmacies in your area are
likely to be part of this network.
You can fill your prescription at any licensed pharmacy, but keep
in mind that if you use a
non-participating pharmacy, you will have to pay full retail price for
the drug and submit claims to LifeWise Health Plan. Also, your benefit
reimbursement will be based on the lower allowable charge at a
participating pharmacy. So it is always to your advantage to use a
participating pharmacy.
To find a participating pharmacy, click
here. You can also call LifeWise Health Plan's Customer Service at
1-888-836-6135 or the toll-free 24-hour Pharmacy Locator Line at
1-800-391-9701 to find a pharmacy in your area or when traveling. |
Cost Savings Programs |
|
LifeWise Health Plan provides the
following cost savings programs. Click on the links for a complete
description of each. |
|
|
Frequently Asked Questions
|
|
Q. |
How much will I pay
for prescription drugs? |
|
A. |
Your benefit will depend upon whether the
drug you receive is a Tier 1, Tier 2 or
Tier 3 drug, and whether you have reached your annual prescription drug benefit
maximum.
Refer to the other LifeWise Health Plan pages on this web site and
your contract for a complete description of the benefit
levels for different drug tiers, cost share and annual benefit
maximum, in addition to other important information about your
prescription drug benefit.
|
|
Q. |
What if I am on a
non-preferred drug and want to stay on it? |
|
A. |
LifeWise Health Plan does not restrict
your ability to get the medications you need. However, if you do use a
non-preferred drug, and there is a generic equivalent available and
allowable by prescription, you will pay the difference in price
between the brand-name and allowable charge for the generic drug, plus
the Tier 3 cost share (50%), up to the cost of the drug.
|
|
Q. |
Are the preferred
drugs just the ones that are the cheapest?
|
|
A. |
No. A committee of physicians and
pharmacists chooses drugs to be preferred only if they are
FDA-approved, safe and effective. When several drugs are similar in
safety and effectiveness, one or more of the lower cost choices are
selected for the preferred drug list.
|
|
Q. |
I've hear that some
people can't take generic drugs. Why not? |
|
A. |
A brand-name drug and its generic
equivalent have the same active ingredients. However, different
manufacturers sometimes use different inactive ingredients to hold the
active ingredients together to make a pill or capsule. In rare
instances, people may have an allergy to the inactive ingredients.
This type of allergy can happen just as often with a brand as with a
generic drug.
|
|
Q. |
How will I know if my
doctor or practitioner prescribes a preferred drug? |
|
A. |
You and your doctor or practitioner will
both receive a copy of the drug list. If you have questions
about your prescriptions, you should talk with your doctor or
practitioner. You can also call LifeWise Health Plan's Customer
Service at
1-888-836-6135 for assistance. The phone number is also on the back of
your LifeWise ID card.
|
|
Q. |
What if I want to get
a brand-name drug even though there is a generic available? |
|
A. |
That is between you and doctor or
practitioner. You can have your prescription filled for a brand-name
drug even when a generic equivalent is available and allowed by your
doctor or practitioner.
However, you must pay the cost difference between a generic and
brand-name, in addition to the applicable brand-name cost share, up to
the total price of the drug.
If your doctor or practitioner requires that you use a brand-name drug
for medical reasons, you will receive the Tier 2 or Tier 3 benefit, as
applicable.
|
|
Q. |
Are there any excluded
categories of drugs?
|
|
A. |
Yes. Even though your benefit covers
non-preferred brand-name drugs, your program excludes drugs used to
treat certain conditions. This includes drugs to treat mental or
psychiatric conditions, drugs to treat obesity or control weight,
drugs prescribed for cosmetic reasons, and drugs to treat infertility
or sexual dysfunction. Refer to your contract for a complete list of
exclusions and limitations.
|
|
Q. |
Can I use any pharmacy
I want? |
|
A. |
Yes, but it is to your advantage to use a
participating pharmacy. If you use a non-participating pharmacy, you
will have to pay the full retail price and submit claims to LifeWise.
Your benefit reimbursement will be based on the lower allowable charge
at a participating pharmacy.
|
|
Q. |
How do I find a
network pharmacy near my home or when I am away? |
|
A. |
Most pharmacies in your area are likely
to be part of the network. Refer to the list of statewide
participating pharmacies in your provider directory. Or click
here for
the online provider directory. There are also participating pharmacies
throughout the United States; the major chains are shown
here. You can also call the toll-free 24-hour Pharmacy Locator
Line (1-800-391-9701) to find a network pharmacy near you.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q. |
My pharmacist gave me a generic product, but I was still reimbursed at
the Tier 2 benefit. Why is this? |
|
A. |
Occasionally, a product that is still
under patent is also made by a second drug company. When this happens,
the second product is not priced as a generic drug, even when the
label uses a generic name.
|
|
Q. |
What if this coverage is secondary to coverage from another health
plan? |
|
A. |
See your contract for an explanation on
how LifeWise coordinates benefits if you have other health care
coverage.
|
|
|
|
|
