Effective July 1, 2000, the Quality Care Plan increased the co-pays for prescription drugs and added a third level of benefit. The prescription plan is administered by National Prescription Administrators (NPA). The following co-pays apply for a 30-day supply:
$7.00—Generic
$14.00—Formulary brand
$28.00—Non-formulary brand
If a brand name medication is dispensed when a generic is available, the member will be charged the cost difference between the brand name medication and the generic medication, plus the $7.00 generic drug co-payment. According to Central Management Services (CMS), a formulary is a preferred medication list that contains an extensive group of medications researched and designed to meet the prescription needs of all types of patients. The formulary has been evaluated by a committee of physicians and pharmacists for side effects and clinical effectiveness. All drugs on the formulary must meet the FDA standards for quality, strength, purity, effectiveness, stability and safety. There are many approved products within each class from which physicians may choose. The formulary list is reviewed quarterly and drugs may be added or deleted.
A member’s physician may fax NPA an appeal at 1-973-560-5615 if the doctor can document that the non-formulary product is medically necessary for the patient. The appeal must document the medical necessity, such as having an adverse reaction to the formulary drug during a trial period.
Additional information on this drug benefit is available on pages 20 and 21 of your “Benefit Choice Options” booklet that was sent to you in May. You may also call NPA at 1-800-250-9594.
