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Drug Coverage Costs
What are drug tiers?
ConnectiCare pays prescription drug benefits using drug tiers. Drug tiers are a way to group drugs according to their cost to you. Generally, you pay less for lower tier drugs and more for higher tier drugs. Your plan states how much you'll pay for drugs in each tier (known as your "copay" or "copayment"), after your deductible. View your plan document for details.
Tier 1 includes generic drugs.
· For most members Tier 1 generics will cost you $5 or less. (Check your plan documents for your costs).
· Generic drugs are equally effective as brand name drugs, as they contain the same ingredients.
Tiers 2 and 3 contain brand-name drugs.
· ConnectiCare covers brand name drugs listed on Tiers 2 and 3.
· Tier 2 drugs are ConnectiCare's preferred brands and tier 3 drugs are non-preferred brands. Tier 2 drugs will cost you less than Tier 3 drugs.
· If your doctor determines that you require the brand name drug when there is a generic version available, you will pay the generic (Tier 1) drug copay PLUS the difference between the full cost of the generic and the brand drug, instead of the brand copay. For example:
| Drug | Brand name drug A | Generic version of drug A | Brand name drug B | Generic version of drug B |
| Full Drug Cost | $100 | None available | $215 | $15 |
| Your Cost | Tier 2 Copay: $25 Because a generic is not offered |
None available |
Tier 1 Copay: $5 PLUS Difference between brand and generic cost: ($125 - $15) $110 _______ $115 Because a generic is offered |
$5 |
Tier 4 covers specialty drugs. These drugs are the highest cost drugs and require special authorization and handling. You can learn more about specialty drugs below.
Generic Drugs & Specialty Drugs
Not all drugs have a generic version. Many drugs are protected by United States patents, which have not expired. Until the patent expires, the company, which owns the patent, is the only company who can produce that drug. Once the patent expires other companies can apply for approval to manufacture a generic version of the drug.
A generic drug is called by its chemical name instead of the brand name chosen by the manufacturer for marketing purposes. For example, acetaminophen is the generic name and Tylenol is the brand name. Unlike other “generic” products, such as generic foods found in the supermarket, generic drugs are required to have FDA approval, just like brand name drugs.
The Food and Drug Administration (FDA), the federal agency that regulates medications, evaluates generic drugs for therapeutic equivalence prior to approval. Therapeutic equivalence means having the same active ingredients as the brand. It also means the generic can be expected to have the same clinical effect.
Physicians are best at choosing which drug is right for you, but they do not always know which drugs are available in a generic version. Your pharmacist is an excellent source for information on which of your prescriptions can be filled with a generic.
Physicians commonly write the brand name on the prescription, since it is the name they are familiar with, knowing the pharmacist will substitute an equivalent generic if available. Pharmacists can substitute the generic version, in most cases, without a call to the physician.
Generics are less expensive because the FDA does not require the generic manufacturer to repeat costly research and clinical trials on the active ingredients already found to be safe and effective. In addition, generic manufacturers do not spend millions of dollars in sales and marketing to physicians, or spend billions on newspaper and television ads to consumers.
Since the cost of brand names is higher than the cost of generic drugs, it is likely that you will be asked to pay a higher copay for the more expensive medication.
Both the brand and generic drugs contain the same active ingredient(s), although different manufacturers may change the drug's color, shape, or size. It is always a good idea to check with the pharmacy that filled the prescription and ask why the medication looks different; in addition, this will also give you a chance to discuss any other questions you may have about your prescription.
Specialty medications are often prescribed for complex or rare conditions. They may be given in a special setting - like a doctor's office or require special handling or storage if taken at home.
Most specialty drugs must be filled by a specialty pharmacy. ConnectiCare partners with Accredo to fill specialty prescriptions, which are most often shipped to your home.
Find the Specialty Drug Prior Authorization List PDF here.
For more information, please visit the Accredo specialty drug pharmacy website.
Prescriptions
Simply take your prescription and your ConnectiCare ID card to any participating pharmacy. Our pharmacy network includes the major chains as well as many local drug stores.
A copayment is the predetermined fee you pay for covered healthcare benefits – in this case, prescription drugs. Your specific copayment for each tier can be found in your Benefit Summary. Your copayment is based on the tier in which the drug is listed.
The cost of drugs varies widely, even among medications that treat the same condition. Generic drugs are the least expensive and therefore have the lowest copayment. Brand name drugs cost on average three to four times as much as generic drugs and therefore have a higher copayment.
The prescription will be filled at a participating pharmacy at the highest copayment amount.
When generic drugs are available, your prescription drug program covers only the cost of the generic. If you or your physician request the brand name when a generic is available, an additional payment is required. This additional payment represents the cost difference between the generic and brand name.
There are several reasons why your copayment could increase.
- Employers purchase health benefits on a yearly basis. If you or your employer made changes in your benefits, prescription copayment levels may have also changed.
- ConnectiCare reviews drugs several times throughout the year. One of your medications may have been moved to a new copayment tier.
- Your physician may have written you a new prescription for a different quantity. Copayments are based on the number of month’s supply dispensed to you by the pharmacy.
A limited number of medications covered by ConnectiCare need prior approval from the prescribing physician. Drugs require prior approval in these situations:
- Drug's that should be monitored to insure appropriate use
- The medication has been prescribed in a quantity over the set limit
Also some drugs are not covered by ConnectiCare, including:
- Drugs used for sexual dysfunction
- Drugs used for weight loss
- Drugs used for smoking cessation
Look for a participating pharmacy. Most pharmacy chains all over the USA participate with the ConnectiCare network.
If you use a non-participating pharmacy, you are responsible for the full cost of the prescription at the time of purchase. However, if there was a medical emergency and you paid for the prescription, keep your receipt and fill out the Prescription Drug Claim form for reimbursement.
Most plans offer home delivery of prescription medications. Refer to your Benefit Summary to see if you're covered for mail order. Our mail order service offers a convenient way to receive up to a three-month supply of the medications you take on an on-going basis. Sign up for home delivery
If you are away from home or plan to be away for an extended period of time, please call Member Services at 1-800-251-7722, and we may allow for an early refill if needed, up to a 30-day supply. Or you may fill or refill a prescription at any participating pharmacy anywhere in the United States and you will only be responsible for your standard copayment amount. See the pharmacy locator to find a participating pharmacy near your destination.
There are three simple ways to obtain one. You can e-mail us, call Member Services or you can view ConnectiCare's prescription drug lists. This version has a search function that will easily allow you to find your medication.
Massachusetts law allows fully-insured commercial health plan coverage of a full 12-month supply refill on oral contraceptives (birth control). What does this mean for you? After receiving an initial prescription, you can receive up to a 12-month supply of birth control in one visit to the pharmacy rather than 12 separate refills for the year. Your doctor can also prescribe a smaller amount if needed.
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Drugs Covered
Use your drug list, or formulary, to see what drugs are covered by your ConnectiCare plan.