LGC Risk Services - Prescription Drugs

Prescription Drugs

According to a recent Prescription Drug Trends report from the Kaiser Family Foundation, spending in the United States for prescription drugs was $200.7 billion in 2005--almost five times more than the $40.3 billion spent in 1990.

These costs can significantly impact a town, city, school, or quasi-municipal organization's bottom line, as well as its ability to cost-effectively meet the medical needs of its employees and their families. By offering benefits programs that provide employees with educational information and financial incentives for making smart prescription drug choices, Member Groups are better able to control overall plan costs.

LGC HealthTrust offers several affordable, short- and long-term prescription drug coverage options. Click on a link directly below to learn more.

SHORT-TERM PRESCRIPTION COVERAGE
LONG-TERM PRESCRIPTION COVERAGE
RETIREE PRESCRIPTION COVERAGE
COST CONTAINMENT

SHORT-TERM PRESCRIPTION COVERAGE
Short-term prescription drugs are those issued in a 34-day supply or less. LGC HealthTrust medical plans offer a wide variety of prescription drug payment and reimbursement structures that meet a broad range of Member Groups' needs. The following descriptions explain how our medical plan offerings address the prescription drug coverage benefit:

Indemnity Plans
Through LGC HealthTrust indemnity plan offerings, covered members and their families may purchase short-term prescription drugs using Anthem Prescription. With a plan ID card that may be shown at any Anthem Prescription network pharmacy, prescriptions are covered at 80 percent after annual deductibles are met.

Because claims are transmitted electronically from the pharmacy, there are no claims forms to complete in order to receive reimbursement. (When appropriate, an Explanation of Benefits is mailed to the Individual Member with reimbursement.)

The following alternative pharmacy cost structure is available to help Member Groups

control the amounts of their overall plan premiums:

$10 copayment for a generic medication
$20 copayment for a preferred brand formulary medication
$30 copayment for a non-preferred brand formulary medication

Other copayment plans are also available to help Member Groups save money while providing quality and effective drug therapy for employees.

Point-of-Service (POS) Plans and Health Maintenance Organization (HMO) Plan
Prescription drug benefits for members covered under our BlueChoice^® POS plans or our HMO option, Matthew Thornton Blue^SM, are provided through Caremark.

Covered members and their families may easily obtain up to a 34-day supply of prescription medication at a retail pharmacy. The standard copayments are $3 for generic medication, and $15 for brand name medication.

The following alternative pharmacy cost structure is available to help Member Groups control the amounts of their overall plan premiums:

$10 copayment for a generic medication
$20 copayment for a preferred brand formulary medication
$30 copayment for a non-preferred brand formulary medication

Other copayment plans are also available to help Member Groups save money while providing quality and effective drug therapy for employees.

LONG-TERM PRESCRIPTION COVERAGE
The Caremark Mail Service Program offers convenient home delivery for up to 90-day supplies of maintenance medication. Prescriptions and refills may be filled through Caremark's delivery service for a low copayment per prescription.

To use the service, members simply ask their doctor to write a prescription for a 90-day supply, plus any appropriate refills. After submitting to Caremark a Caremark Mail Service Order Form and the copayment for each prescription, medications arrive via U.S. mail or UPS within 14 days.

Refills or renewals may easily be requested by linking to Caremark at www.caremark.com or by calling 888.726.1631.

A variety of benefit options are available through LGC HealthTrust medical plans. Following are brief explanations of how the various medical plan offerings provide affordable, long-term prescription drug coverage for covered LGC HealthTrust members and their families:

Indemnity Plans
For members covered under our indemnity programs, the standard copayment is $1 for a 90-day supply of maintenance medication through the Caremark Mail Service Program.

Additional copayment structures are available to help Member Groups lower their overall plan premiums and accommodate employees' individual prescription drug needs.

The following alternative pharmacy cost structure is available to help Member Groups control the amounts of their overall plan premiums:

$10 copayment for a generic medication
$20 copayment for a preferred brand formulary medication
$30 copayment for a non-preferred brand formulary medication

Other copayment plans are also available to help Member Groups save money while providing quality and effective drug therapy for employees.

Point-of-Service (POS) Plans and Health Maintenance Organization (HMO) Plan
Up to a 90-day supply of maintenance drugs are available through the Caremark Mail Service Program for members covered under the BlueChoice^® POS plans or our HMO option, Matthew Thornton Blue^SM.

The standard copayment for a home-delivery generic or brand name medication is $1. The following alternative pharmacy cost structure is available to help Member Groups control the amounts of their overall plan premiums:

$10 copayment for a generic medication
$20 copayment for a preferred brand formulary medication
$30 copayment for a non-preferred brand formulary medication

RETIREE PRESCRIPTION COVERAGE
Prescription drug benefits for the Medicare supplemental plan are provided for LGC HealthTrust Medicare-eligible retirees through Caremark. The program provides a variety of coverage options for short- and long-term prescription drug benefits, including the easy-to-use Caremark Mail Service Program that members enjoyed as active employees.

Other copayment plans are also available to help Member Groups save money while providing quality and effective drug therapy for employees.

COST CONTAINMENT
Balancing healthcare needs with available resources can be an ongoing challenge. In collaboration with Caremark, LGC HealthTrust uses a variety of cost containment measures to uncover and address drug utilization patterns that help to lower the overall costs of health plans and ensure plan participant safety. These savings are then passed directly onto our Member Groups. The following provides an explanation of each measure:

Concurrent Drug Utilization Review
A drug interaction occurs when certain drugs act together to result in an adverse effect on the body. Under the Concurrent Drug Utilization Review program, every prescription in the Caremark clinical database is automatically screened against a plan participant's profile for potential drug interactions.

For example, if there is a question about a plan participant's prescription, the pharmacist may contact the individual plan participant's doctor before dispensing the medication. The drug utilization review is especially important for those plan participants (or covered dependents) who take many different medications, or see more than one doctor. These "real-time" interventions in patient care help to prevent adverse reactions, improve appropriate prescribing rates and accurately enforce administrative rules.

For plan participants that obtain their prescriptions through the Caremark Mail Service Pharmacy, additional drug safety and optimal drug utilization screening is performed prior to dispensing. Caremark clinical pharmacists may contact an individual’s doctor to suggest alternative therapies that reduce pharmacy cost and reduce potential adverse events. These suggestions are based on national guidelines and evidence-based clinical literature.

Retrospective Drug Utilization Review
The Caremark Retrospective Drug Utilization Review program evaluates our entire plan participant population for inappropriate utilization of prescription drugs, ensuring that all plan participants receive optimal drug therapy management.

In this program, Caremark continuously evaluates plan participant profiles for compliance to clinical guidelines by identifying patterns of inappropriate prescribing, dispensing, consumption, drug-drug conflicts, drug-disease conflicts, drug-age/sex conflicts, therapeutic duplication, appropriateness of drug regimen (including dosage and duration), and overutilization and underutilization. If issues are found, Caremark then generates a clinical communication directly to the doctor for review and possible changes in the drugs being prescribed.

The Retrospective Drug Utilization Review program plays a key role in ensuring that LGC HealthTrust plan participants are able to benefit from the highest-quality prescription drug coverage possible.