Tiered Copayments

Most PBM Plus administered pharmacy benefit plans utilize a tiered copayment arrangement; most are three-tiered and some are two-tiered. A few entities provide pharmacy benefits to their members that do not require a copayment of the member.

Three-Tier: This is the most common copayment arrangement. It requires members to pay a low copayment for generic drugs (normally $5 - $15) and higher copayment for "preferred" brand-name drugs (normally $20 -$40) and the highest copayment (typically greater than $50) for brand name drugs not on the Preferred Drug List. In order to save your patients money, we recommend that whenever possible and appropriate for their medical condition that you prescribe a drug that is generically available first, a drug on the "Preferred List" second and reserve the prescribing of drugs not available generically and not on the preferred list as last.

Two-Tier: This plan design requires members to pay a low copayment for any generic drugs they receive and a higher copayment for any brand name drugs; the "Preferred List" does not impact the copayment under these plans.

Generics

Most pharmacy benefit plans provide coverage for most drugs that are FDA approved. At the same time, most plans require that members who, for any reason, receive a brand name version of a product that has an available FDA approved generic, must pay the applicable brand name copayment and the difference in cost between the available generic and brand name drug received. A list of drugs that fall into this category is available at Most Commonly Prescribed Generics. Members typically are required to pay only a small copayment when receiving generic drugs and a substantially larger copayment when receiving brand name products. PBM Plus encourages physicians to write for prescriptions that are the most appropriate to treat their patients' condition but also encourages physicians to prescribe drugs that are available generically whenever possible and appropriate.

Mail Service / Extended Prescription

Most pharmacy benefit plans offer a mail service option to members. Through the mail service option members typically receive a 90 day supply of medication while receiving a reduction in co-payments. PBM Plus encourages the use of mail service whenever possible and practical for members. PBM Plus also recommends that before any prescription is filled for an extended day supply, that the patient has been using the medication for a minimum of fifteen (15) days to determine that the medication and strength is correct for the patient's condition. When writing for a new prescription, health care practitioners are encouraged to provide the patient with samples or write a prescription for a 30 day supply for members to have filled at their local pharmacy. A second prescription for a 90 day supply, with appropriate refills (up to 3 refills) can be written for the patient to have filled at the mail service pharmacy once the health care practitioner has determined that the medication is providing the optimal clinical response for the patient. Health care practitioners are encouraged to not write prescriptions for extended days supplies for patients who they believe may not use the medication appropriately. PBM Plus does not encourage the dispensing of more than a 30 day supply of Class II controlled substances.