Prescription Drug Benefits . . .

The MMEHT has a five-tier prescription drug program. The five tier program introduces a new “Tier 1-Select Generic” category with a lower copayment, slightly higher copayments for Tier 2 and Tier 3 medications, and a new “Tier 4-Specialty and Lifestyle” for the highest cost medications. The Health Trust’s prescription drug program is administered by Express Scripts

 MMEHT Prescription Benefit Design

	Benefit	Copay Active Medical Plans and Retiree Plan
Retail (at the Pharmacy) – up to 30 day supply
	Tier 1 (Select Generic)	$4
	Tier 1 (Standard)	$10
	Tier 2	$30
	Tier 3	$50
	Tier 4	$60
Maintenance (at the Pharmacy or via Mail Order) – 31-90 day supply
	Tier 1 (Select Generic)	$8
	Tier 1 (Standard)	$20
	Tier 2	$60
	Tier 3	$100
	Tier 4	$120

Links For More Information:

• How are the tiers determined?
  
  
• What do the tiers mean?
  
  
• How will you know in which tier your drug falls?
  
  
• What are the Copays Under the Health Trust’s Prescription Drug Program?

 

 

 How are the tiers determined? 

Our health plans use a "Preferred Drug List" containing brand-name and generic medicines approved by the Food and Drug Administration (FDA) and reviewed and recommended by Anthem’s Pharmacy and Therapeutics (P&T) Committee.  The P&T Committee is an independent group of practicing doctors, pharmacists and other health care professionals responsible for the research and decisions surrounding our drug lists. This group regularly meets to review new and existing drugs and chooses the medicines for our drug lists for several reasons, including their safety, value and how well they work.

Drugs on the Drug List are grouped into tiers. There are several factors that are used to determine under which tier a drug will be put in. This can include (but it’s not limited to): • Cost of the drug • Cost of the drug in comparison to other drugs used for the same type of treatment • Availability of over-the-counter options • Other clinical and cost factors.
When you use the prescription medications on the “preferred” list, or formulary, you will pay a lower copay than if you were using medications that are considered as “non-preferred” by Anthem.  Most generic medications are included in Anthem’s formulary, and are subject to one of the lower copays in the program.  The formulary also includes many brand name medications, for which you will usually pay a higher copay.    Certain prescription drugs may be excluded when better value, clinically-equivalent medications in the same therapeutic class are available.  Please contact the MMEHT at 1-800-852-8300 for more information. 

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What do the tiers mean?  

Tier 1-Select Generic drugs have the lowest Copay. These Select Generic drugs offer the greatest value within a therapeutic class. Select Generics are the most commonly prescribed and proven generic medications that are known for effectiveness and value in treating many medical conditions.  All of these are generic equivalents of brand name drugs.

Tier 1-Standard drugs have the second lowest Copay. These drugs offer the good value within a therapeutic class. Some of these are generic equivalents of brand name drugs.

Tier 2 drugs have a mid-range Copay.  These drugs may be preferred brand drugs and possibly newer, more expensive generic drugs based on clinical effectiveness and value.

Tier 3 drugs have a higher Copay.  These drugs may be higher cost brand name drugs and some generics that may cost more than therapeutically equivalent drugs.These drugs may include medications recently approved by the FDA.

Tier 4-Specialty and Lifestyle drugs have the highest Copay.  These Specialty and Lifestyle drugs may be the highest cost brand name drugs and some generics that may cost more than therapeutically equivalent drugs.These drugs may include medications recently approved by the FDA.  Specialty drugs are most commonly prescribed to treat complex, chronic conditions and may require special handling and/or management.  Lifestyle drugs are most commonly prescribed to treat impotency.

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How will you know in which tier your drug falls? 

Select Generic drugs offer the greatest value within a therapeutic class. Select Generics are the most commonly prescribed and proven generic medications that are known for effectiveness and value in treating many medical conditions.  All of these are generic equivalents of brand name drugs.   You can review the current listing of the Select Generic drugs to see if your medication falls under this tier 2012 Tier 1 Select Generic Prescription List

Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. This approval process is called prior authorization.  Anthem has a website that will allow you to check your prescription to see if it needs approval of benefits before filling the medication, or if there are limits on the quantity that you can receive: Anthem’s Prescription Drug Information

If you have a health problem that needs to be treated with complex drugs, your medication may fall into the Specialty drug tier. Specialty drugs are those drugs that come in different forms including oral (i.e., drugs taken by mouth, like pills or liquids) but are often injected, infused or inhaled. They most often need special storage and handling, need clinical monitoring, cost a lot of money and are given to a patient by a doctor or a nurse. You can review the current listing of the Specialty drugs to see if your medication falls under this tier Specialty Drugs List

You can also contact the Health Trust at 1-800-852-8300 (in Maine) or 207-621-2645 (out of state) or by email at htservice@memun.org.  The Health Trust Service Representatives can look up your particular medication to see which tier it falls into.

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What are the Copays Under the Health Trust’s Prescription Drug Program? 

The Trust’s health insurance programs, including the retiree Group Companion Plan program, offer the same prescription drug benefits.  The copays are shown in the chart at the top of this page and on each health insurance summary.

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