Prescription Drug Coverage for Traditional and PPO Enrollees is updated and modified as follows:

Drug Co-Payments: Effective January 1, 2004 the program will provide for the following drug co-payments, applicable for each prescription or refill.
Retirees and surviving spouses as of 9/18/03, the surviving spouses of such retirees, and their covered dependents:
  Retail 34-day supply of Generic drugs:  $5.00
  Retail 34-day supply Brand Name drugs:  $5.00
  Mail Order 90-day supply of all Generic & Brand Name drugs prior to 1/1/05:  $2.00
  Mail Order 90-day supply of all Generic & Brand Name drugs on/after 1/1/05:  $5.00

All other Enrollees  (i.e. Active Workers on 9/18/2003. Those who retire on or after 9/18/2003, surviving spouses of such employees/retirees and their eligible dependents)
  Retail 34-day supply of Generic drugs:  $5.00
  Retail 34-day supply of Brand Name drugs:  $10.00
  Mail Order supply: All Generic & Brand Name drugs prior to 1/1/05:  $2.00
  Mail Order supply: All Generic & Brand Name drugs on/after 1/1/05:  $5.00

The co-payments listed above are generally for up to a 34-day supply at retail and a 90-day supply at mail order. Certain covered drugs come in pre-packaged quantities exceeding these day limits. If these pre-packaged drugs cannot be repackaged by the pharmacy the appropriate co-payment will be pro-rated to account for the additional days supply.

Dispensing of Generic Drugs: If an Enrollee presents a prescription for a Brand Name drug that has a Generic equivalent, the pharmacy (either retail or mail order) will dispense the Generic equivalent and the Enrollee will pay the applicable Generic co-payment, except as follows:

Prescription drug coverage for Traditional and PPO Enrollees
At a retail pharmacy, if the Brand Name drug is dispensed at the Enrollees request, the Enrollee will pay the appropriate Generic Drug co-payment plus the full difference in the program cost between the Generic Drug and the Brand Name drug. If the Brand Name drug is dispensed at a retail pharmacy and at the physician's direction, the Enrollee will pay the appropriate Brand Name co-payment plus the difference (up to a maximum of $10) in program cost between the Generic and the Brand Name drug. Thereafter there will be a review of the medical necessity for dispensing the Brand Name Drug rather than the Generic. If such medical necessity is established, the amounts paid by the Enrollee in excess of the Brand Name co-payment will be refunded and the carrier's systems will be adjusted to allow for dispensing of the Brand Name drug for as long as the Enrollee continues to take the drug. If the medical necessity is not established, future dispensing of the Brand Name drug will require the Enrollee to pay the appropriate Generic drug co-payment plus the full difference in the program cost between the Generic drug and the Brand Name drug.

At the Mail Order Pharmacy: If the physician directs dispensing of a Brand Name drug, the mail order pharmacist automatically will initiate a review of the medical necessity of the Brand Name drug rather than a Generic before dispensing it. If such medical necessity is not established, the Brand Name drug will be dispensed and the Enrollee will pay the required mail order co-payment, plus the full difference in program cost between the Generic drug and the Brand Name drug.

There are a small number of Brand Name drugs that have Generic equivalents, but for which small variations in the dose could result in changes in drug safety. These drugs are not subject to the Generic dispensing provisions explained above. When these Brand Name drugs are dispensed, only the Brand Name co-payment will apply, and the differential between the Generic and the Brand Name program cost will not be charged to the Enrollee.

Use of the Mail Order Pharmacy: Under the 1999 program, over 120 drugs commonly referred to as "maintenance drugs" could be purchased in greater than a 34-day supply at a retail pharmacy. Effective January 1, 2004 coverage at retail will be limited to a maximum 34-day supply. After the original prescription order and two refills, retail purchases of such drugs will be subject to an Enrollee co-payment of 100% of the program cost. However, these drugs will continue to be available at mail order for a 90-day supply at the appropriate mail order prescription drug co-payment. Drugs may be added to or deleted from this list from time to time.

Hopefully this article will help the Membership to understand the changes in the drug program. If you have any questions they can be directed to this office at 304-267-5639.

Joe Hellane
Rick Walker
Rodney Aikens
Kevin Tucker

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