Magazine article Drug Topics

Multitier Co-Pays Emerge at Two Managed Care Groups

Magazine article Drug Topics

Multitier Co-Pays Emerge at Two Managed Care Groups

Article excerpt

At first, there were only two tiers of copayments--one for brandname drugs and a lower copay to encourage use of generic drugs. Then managed care companies and pharmacy benefit managers established formularies and created a higher third tier for brand-name drugs not listed on the formulary.

Now two of the largest managed care groups have broken the threetier limit, announcing four- and five-- tier co-pays to be implemented soon. Humana calls its program Rx4 to describe its new system of four copay levels. Express Scripts is proposing a five-level system, which it says will give employers more flexibility.

Both organizations claim pharmacists will have no trouble determining the co-pay since the new tiers will be integrated into their computer programs. However, when patients are asked for a larger co-pay, they will turn to the pharmacist for answers.

"The pharmacist will bear the brunt of consumer questions as well as complaints," said Phillip Schneider, v.p. of external affairs and program development of the National Association of Chain Drug Stores. He noted that an NACDS study showed that R.Ph.s spend a great deal of their time dealing with plan administrative problems that patients encounter.

"We're trying to drive choice for our members to get them to the pharmaceutical choices they want," said Mary Sellers, corporate spokeswoman for Humana. "We looked at prescription drugs based on our own claims information and organized our co-pays and the drugs into four tiers."

The four levels of Humana's Rx4 program are as follows:

* Level One includes low-cost generic and brand drugs and requires the lowest co-pay of around $10, depending on the area and the cost negotiated by the employer group on behalf of employees.

* Level Two includes higher-cost generic and brand drugs and requires a higher co-pay of about $25.

* Level Three includes mostly brand drugs that have generic or brand therapeutic options in Levels One or Two and require a higher co-pay of about $45.

* Level Four includes hightech drugs, such as certain brand drugs, biotechnology drugs, and some selfadministered injectables, which require a 25% co-pay.

Sellers pointed out that patients have a maximum co-pay of up to $2,500 for Level Four drugs, after which Humana covers the full cost

The five-tier plan proposed by Express Scripts is organized differently Some drugs have higher value because they provide benefits that are life-enhancing, explained Fred Teitelbaum, vp. …

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