In an effort to control the Health Fund’s rapidly rising expenditures for certain drugs, the Trustees have adopted a mandatory “generics first” program for drugs that treat high cholesterol, high blood pressure and acid reflux, eczema and psoriasis, sleep disorders and, allergies (nasal sprays). Under this generic program, the Fund will pay only for generic drugs in these classes (unless the medical necessity for a brand name drug has been established by a participant’s physician). This means that prescriptions written for non-generic versions of these classes of drugs, will, in most cases, not be paid for by the Fund, unless you doctor establishes the medical necessity of using such non-generic drug.
Generic drugs in these classes will be paid for under the generic drug benefit currently provided by the Fund (e.g., after the $100 annual deductible has been satisfied, prescriptions filled at a network pharmacy will be paid for in full after a copay of $10 or 20% of the cost of the drug, whichever is greater, has been satisfied). Members taking any other type of drug (that is, all drugs outside of these categories) are not affected by this policy. Neither are members who are already taking generic versions of the six aforementioned categories of drugs.This program is called “FlexPay” and it offers an optional way of purchasing a 90-day supply of mail-order drugs. FlexPay allows you to divide your normal up-front copay cost for a three-month supply of prescription drugs into three smaller payments.
There is no doubt that drugs in these categories can be vital for patients with the conditions they treat, and the growth in their popularity is likely to lead to improved health for millions over the long run. However, it is also true that the popularity of these medications has caused pharmaceutical companies to focus on maximizing their profits on these categories of drugs. Often this means launching a “new and improved” version of a drug that for most patients has few, if any, advantages over existing treatments, but which affords the pharmaceutical companies greater opportunity for profit because these new drugs have patent protection from competitors. Even when drugs lose their patents, drug companies will claim that their “brand name” is superior to the newly available generic versions of the drug, even though the generic is chemically identical to the original (patented), version of the drug (the only real difference may be the binder or color used in manufacturing the drug).
For instance, Nexium may be only marginally better for treating acid reflux than its therapeutic equivalent - generic Prilosec, yet Prilosec costs approximately $50 per 30 day supply, versus $200 for Nexium. Similarly, the generic version of Zocor might cost approximately $15 for a 30 day supply, but the same supply of its brand equivalent Crestor might cost $125. Therefore, when you use brand name drugs instead of generics, you may be unnecessarily increasing the cost of those drugs to you and the Fund, by as much as 4 or 7 times, or even more, with no added benefit to you.
If your doctor feels the brand name version of the drug is medically necessary for you, he/she can appeal to CIGNA by contacting them at (800) 244-6224 for a waiver of the generic requirement. Such a waiver can also be granted if you have already tried a generic version of the drug within the past 18 months without success.
There is a link on CIGNA’s web-site that explains generic drugs and lists such drugs in the categories discussed above:
What are Generic and Therapeutically Equivalent Drugs?
A generic drug is identical or bioequivalent (rate and extent of absorption is the same) to a brand name drug. It is identical in terms of dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. Although chemically identical to their brand name drug counterparts, generic drugs are typically sold at much lower prices than brands. The Congressional Budget Office has estimated that generic drugs save consumers $8 to $10 billion a year at retail pharmacies. (That does not count the estimated billions saved by hospital use of generics).
Drug companies must submit a drug application to the FDA (and receive its approval) in order to sell a generic product. The application process does not require that animal and clinical research be reported on ingredients or dosage forms already approved for safety and effectiveness. However, to secure gain FDA approval, a generic drug must have:
• The same active ingredients as the original drug (inactive ingredients can vary)
• Identical strength, dosage form, and route of administration
• The same use indications
• Meet the same batch requirements for quality, identity, strength and purity
• Be manufactured under the same strict standards of FDA’s good manufacturing practice regulations required for brand names
A therapeutically equivalent drug is a drug that is in the same clinical classification that can be substituted with the expectation that the substituted product will produce a similar clinical effect with a similar safety profile as the prescribed product.
Is A Generic Drug Available For The Brand Name Drug I’m Taking?
You can find out by going to the CIGNA website at www.cigna.com and, on the “Customer Care” menu at the left, clicking on the “Drug Lists” link. From there, you can key word search your specific drug by entering the name of the drug and clicking on the name of the drug that appears on a the pop-up list, then clicking on “Go”. At that time, the website will show you whether a generic alternative is available for that specific medication. Additionally, you can click on the “Drug Class/Type” link on the right of the results. That will bring up a list of any medications that are therapeutically equivalent to the brand name drug you entered and indicate whether that equivalent is available in a generic version.
This CIGNA web resource applies to all medications you may be taking. If the medication you are searching happens to be one subject to the mandatory generic program, it will have a “ST” designation on the CIGNA website, indicating the product would be subject to Step Therapy (another term for our mandatory generic program). If there is no ST, the brand name may be available under the mandatory generic program even though that drug is generally not covered, because no drug suitable generic is available at that strength. You can also call CIGNA at 1-800-244-6224 and get the same information that is available through their web-site.
What If I Try A Generic Drug And It Does Not Work For Me?
If you try a generic version of a drug and that version does not work well for you, or generates side effects that you did not experience with a brand name drug, you have at least two avenues to explore.
First, you can try another generic. That may well work for you. If it does, you’ll save money and so will the Fund.
If you have already tried the available generics, and they have not been satisfactory and your physician feels a brand name drug may work better, that physician can apply for a waiver of the generic requirement.
Getting Prices For Brand Name And Generic Drugs
CIGNA offers a pricing tool that enables you to compare the costs of drugs. In order to access this tool, you go to www.mycigna.com and log-in. Then, under the heading “My Plans” click on the “View Pharmacy Main Page” tab. That will take you to a screen where you can scroll down to see an area entitled “Prescription Drug Price Quotes” and click on “Go”. You will now be able to enter the name of any drug, and a list with one or more drugs will appear (you can also use the “A-Z” tab, “Class/Category” tab or “Conditions” tab to find your drug). Click on the name of the drug that matches your inquiry. Choose the appropriate dosage and frequency and click on “Select a Pharmacy”. Then click on the box next to any pharmacy for which you wish to check the price. Then click “Compare Prices”. On that page you will see the price of the drug and a comparison with the price to any available generic alternative, as well at the price through the mail order CIGNA Tel-Drug program.
Entering that name will not only provide a price estimate for that drug, but it will bring up any available drug that is a generic or therapeutic alternative to that drug and provide a price estimate for that as well. So you will be able to see your alternatives and estimate the savings that may be available if you use the alternative instead of the brand name drug. The savings available through the Tel-Drug program will also be displayed. You can also call CIGNA at 1-800-244-6224 and get the same information that is available on their web-site.
FlexPay Makes Mail Order Drug Purchases More Affordable
Using mail order prescriptions will nearly always result in lower copays and other costs for the same quantities of drugs purchased on a retail basis. So using mail order will save you, and the Fund, money. However, mail order prescriptions are generally filled in 90 day supplies, versus the 30 day supply that is typical at retail pharmacies. Consequently, while copays will only be due on mail order prescriptions every 90 days, those copays will be considerably higher than the copay for a 30 day supply in a retail setting. We recognize that some members with high drug costs may find the more uneven mail order copay schedule burdensome. In order to address this issue, we are pleased to tell you about a new service that is now available.
This program is called “FlexPay” and it offers an optional way of purchasing a 90-day supply of mail-order drugs. FlexPay allows you to divide your normal up-front copay cost for a three-month supply of prescription drugs into three smaller payments.
How does FlexPay work?
Your copay for a 90 day drug supply will be divided into three equal payments. The first payment will be automatically charged to your credit card when the order is shipped. The second payment will be charged on the 15th of the following month (second month). The third payment will be charged on the 15th of the following month (third month).
In order to use FlexPay, your coinsurance must be at least $150 for the mail-order prescription. If it is, the program is available for all mail-order prescriptions. Please note that failure to comply with the payment arrangements could result in a delay of your next orders.
What do I need to do?
Registering could not be simpler. Have a credit card handy when you call CIGNA Customer Service at 1.800.835.3784, and be sure to mention that you are interested in the Equity League FlexPay program. You will be able to sign up right over the phone. Your next mail order will be automatically charged to your card when the order is shipped.
If you have any questions or concerns, or would like more details, please feel free to call CIGNA Customer Service at 1.800.835.3784, or the Fund Office, at 212.869.9380.