Prescription Drug Coverage
What is a generic drug?
A generic drug is a "copy" of a brand name drug. It is usually made by a different company. Before approving a generic drug, the U.S. Food and Drug Administration (FDA) checks it. The FDA compares it to the brand name drug.
The FDA makes sure that the generic drug has the same amounts of the same active ingredients as the brand name drug. The generic drug must come in the same dosage as the brand name drug. It must be absorbed into the bloodstream the same way. It must meet the same quality standards. And it must meet the same standards for safety and effectiveness.
Generic drugs may contain different inactive ingredients. These include colors, flavors, and fillers added to the medicine.
Generic drugs may look different. They may have a different color, shape or size than the brand name drug. But they have the same active ingredients. This is why generics work as well as brand name drugs.
Why we cover generics
Generic drugs work as well as brand name drugs, but cost far less. Generic drugs can cost half as much as brand name drugs. And in some cases, the savings can be much larger.
Health care costs are on the rise. Pharmacy costs are increasing even faster. When a generic drug is available, Health Partners covers only the generic. We do not cover the brand name drug. This helps hold down the cost of health care for our members. This helps us provide the coverage you need. It also helps us offer you extra benefits.
Why generics cost less
Some people believe you get what you pay for. But with brand name drugs, what you're really paying for is advertising. You're paying for ads on radio and TV, and in newspapers and magazines. You're also paying for the drug sales people who visit doctors and hospitals.
The high cost of brand name drugs is important to drug companies. It helps them get back the money they spend on research. This helps with the discovery of new drugs. That's why a brand name drug is protected by a patent for up to 20 years. After a patent runs out, other drug companies can make generic versions. These are usually sold at much lower prices. Until the patent runs out, other companies usually cannot make generic copies.
Due to patents, you can't get a generic version of every brand name drug. But when you can get the generic drug, it can help save money.
Sometimes, when one drug isn't offered as a generic, there may be another drug that can help you. This other drug may come as a generic. Ask your doctor.
Many health plans, the federal government and others suggest using generics. Ask your doctor to prescribe covered generic drugs, whenever possible.
If your medicine is not listed
There may be occasions when a medication you are currently taking for your condition is not listed on the formulary. If your doctor would like you to receive this medication in place of one that is on our Formulary, your doctor will need to call Health Partners for a prior authorization. Please talk with your doctor about using medications that are listed on the formulary.
We stay in touch with all Health Partners participating physicians and pharmacies. We give them information about your pharmacy benefit and the formulary. If you receive a prescription for a non-formulary medication, the pharmacist may call your doctor. The pharmacist may ask about changing the prescription. If your doctor cannot be contacted, you usually will receive a temporary supply of medication.
You will get a 3-day supply if it is a new prescription for you (not part of an ongoing treatment. You will get a 15-day supply if the medication is one you have been receiving on an ongoing basis (without a break in treatment of more than 34 days). You will also get a 15-day supply if it is a medication ordered on an "as needed" (PRN) basis (without a break in treatment of more than six months). During this time Health Partners will review your doctor's request to cover the drug.
Your doctor can contact Health Partners if he or she believes that it is medically necessary for you to receive a non-formulary medication. Your doctor can request a medical exception for this drug. If Health Partners does not approve your doctor's medical exception request, you may file a grievance with Health Partners. You may also request an expedited (48-hour) grievance, and/or a DHS Fair Hearing Appeal. Please see your Health Partners Member Handbook for more information.
All Health Partners members under 18 receive full pharmacy services at no charge. If you are 18 or over, you also may be eligible for prescription drugs with small copays.
If you need medicine, your PCP or specialist will write a prescription. Simply take the prescription slip to a participating pharmacy (drug store). More than 600 area pharmacies accept Health Partners. Your prescription will be filled if you are eligible.
Sometimes, by mistake, you may be charged more than you should for a prescription. If this happens, please call Member Relations from the pharmacy for help.
Sometimes your PCP may say you or your children need to have over-the-counter items. Your PCP will give you a prescription for these items. Take it to a participating pharmacy. Over-the-counter items that we cover include:
- Tylenol or aspirin
- sinus/allergy medicines
- surgical supplies
Restricted Recipient Program
Health Partners takes part in the Pennsylvania Department of Human Services Restricted Recipient Program. If a member's use of prescriptions or medical services shows signs of over use, abuse or fraud, we will refer the member to this program. After reviewing the matter, the Department may ask Health Partners to place the member in the program. This limits the member to one participating plan pharmacy and one physician unless approved by his or her PCP. He or she must use only this pharmacy to get prescriptions filled. These restrictions do not apply to emergency services.