FAQ
Basic Drug Option

How does the $7 generic/50% ($125) brand option work?

How does the $4 generic/brand discount option work?

How can members take advantage of these drug options?

What is the difference between a brand-name and a generic equivalent drug?

What if a member is taking a brand-name drug that does not have a generic equivalent?

What is a generic therapeutic alternative?

Why wouldn't a generic equivalent be available?

Is there a formulary?

How does mail order work for these options?

How much will members pay at mail order?

Do procedures that support safe prescribing practices, including prior authorization, age, gender, and quantity limits, apply to these options?

Where can members get drug pricing information?

Will the eliminated options be grandfathered?

Do the drug cost-sharing amounts for these drug options apply to the medical out-of-pocket limits?

How does the $125 maximum member payment per brand prescription work?

How are self-injectables covered under these drug options?

How does the $7 generic/50% ($125) brand option work?
Members pay $7 for each generic prescription filled at a participating retail pharmacy. For brand prescriptions, members pay 50% of IBC's discounted price up to $125 per prescription. Members do not have to pay more than $125 per brand prescription at a participating retail pharmacy.

How does the $4 generic/brand discount option work?
Members pay $4 for each generic prescription. For brand prescriptions, members pay 100% of IBC's discounted price. There is no maximum, so members are responsible for paying the full discounted amount.

How can members take advantage of these drug options?
Members have several ways to take advantage of the savings available under these Basic drug options:

• Members with a new prescription are encouraged to discuss the use of generic drugs with their doctor. If their doctor agrees that a generic drug is appropriate, members should ask the doctor to write them a prescription for the generic drug.
• Members with an existing brand prescription that has a generic equivalent should ask that a generic be provided instead of the brand at the next refill. If their doctor indicated on the original brand prescription to "Dispense as Written," members can request that the pharmacist fill/refill the prescription with the generic. The pharmacist may contact their physician.
• Members with an existing generic prescription may continue to use the generic drug. Their copayment/coinsurance will be $7 or $4, depending on their benefits option.
• Members with an existing brand prescription that has a generic therapeutic alternative available for the brand name drug they are currently using should discuss the use of the generic drug with their doctor and, if appropriate, obtain a new prescription for the generic therapeutic alternative.

What is the difference between a brand-name and a generic equivalent drug?
According to the Food and Drug Administration, generic drugs are the same as their brand-name counterparts in active ingredients, dosage, safety, strength, and performance and are held to the same strict standards as the brand-name drug. The only noticeable difference between a generic and its brand-name counterparts may be the shape and/or color of the drug. While generic drugs are just as effective as the corresponding brand-name drugs, they typically cost up to 70 percent less, helping control health care costs. It also helps keep members' out-of-pocket costs down.

What if a member is taking a brand-name drug that does not have a generic equivalent?
If there is no generic equivalent, members are encouraged to discuss generic therapeutic alternatives with their doctor and have their physician write a new prescription, if appropriate. If a member's brand drug is not available in generic form, there may be another generic drug that could work just as well.

What is a generic therapeutic alternative?
A generic therapeutic equivalent is a drug that is used to treat the same condition that a brand drug may treat but does not have the exact chemical makeup as the brand drug. If a therapeutic equivalent is unavailable, a therapeutic alternative is another drug in the same class that can treat the same condition.

Why wouldn't a generic equivalent be available?
During the time a brand-name drug is protected under patent, a generic equivalent may not be made. During this patent protection time, many patients and doctors, in the interest of saving money and maintaining optimal health, will discuss the option of substituting a generic therapeutic alternative. A therapeutic alternative is actually the generic equivalent for a different brand-name drug and treats the condition using a different active ingredient. For most of these patients, these substitutions work just as effectively.

Is there a formulary?
These drug options do not utilize the Select Drug Program^® formulary.

How does mail order work for these options?
Mail order is available for up to a 90-day supply for generic and brand drugs. Members must submit a prescription to the mail order facility and the prescription will be mailed to the member within 10 to 14 days.

How much will members pay at mail order?

• $4 generic/brand discount - $8 per 90-day supply of generic drugs and 100% the discounted price of a 90-day supply of brand drugs.
• $7 generic/50% brand ($125) - $14 per 90-day supply of generic drugs and 50% coinsurance up to a $250 maximum member payment per brand prescription for up to a 90-day supply.

Do procedures that support safe prescribing practices, including prior authorization, age, gender, and quantity limits, apply to these options?
Yes, Procedures that Support Safe Prescribing practices apply to these drug options.

Where can members get drug pricing information?
Members can get drug pricing information by logging onto ibxpress.com and clicking on Find a Prescription drug.Members can also call FutureScripts^®* Customer Service at 1-888-678-7012.

Will the eliminated options be grandfathered?
Yes, the eliminated options will be grandfathered for existing groups. Standard small-market group (2-50) and mid-market group (51-99) grandfathering rules apply. If a group makes a medical or drug benefit change, it must select from one of the drug options in the current product portfolio. Large groups (100+) may continue to offer the grandfathered drug options.

Do the drug cost-sharing amounts for these drug options apply to the medical out-of-pocket limits?
No, the drug cost-sharing amounts for these drug options do NOT apply towards the medical out-of-pocket limits.

How does the $125 maximum member payment per brand prescription work?
For each brand prescription purchased, the member is responsible for 50% of the discounted cost (but no more than $125 per retail prescription). So, $125 is the most that a member will pay for a brand name drug at participating retail pharmacies (or $250 for a 90-day supply through mail order). The maximum provides protection for the member against very high drug costs.

How are self-injectables covered under these drug options?
Any generic self-injectables are covered at the generic copay. Brand self-injectables are covered differently, depending on the plan:

• $4 generic/brand discount - Brand self-injectables are not covered, but members may take advantage of IBC's discounted price at participating retail pharmacies. Brand drugs are also available through mail order at a discounted price.
• $7 generic/50% brand - Brand self-injectables are covered at 50% coinsurance up to the $125 maximum member payment per prescription at participating retail pharmacies. Brand drugs are also available through mail order with 50% coinsurance, up to a $250 maximum member payment per 90-day supply.

* FutureScripts^® is an independent company and serves as Independence Blue Cross’ pharmacy benefits manager.