Pharmacy Benefits
Your Pharmacy benefits under UT SELECT are administered by Medco Health Solutions (Medco) and require a $50 annual deductible per person, per plan year. Your prescription drug program offers three different benefit levels based on the drug category.
As described below, My Rx Choices will help you make the most of your prescription benefits. Your UT SELECT prescription program allows you to utilize both the retail pharmacies and the mail order pharmacy. Most retail pharmacies participate in the nation-wide Medco retail pharmacy network.
UT SELECT Pharmacy Benefits
| Access Options |
Generic Drug Copayment |
Preferred Drug Copayment |
Non-Preferred Drug Copayment |
| Annual Deductible |
$50/person/year (Deductible does not apply to medical plan deductible) |
| Retail Network Pharmacy: Up to a 30-day supply*. Refills allowed as prescribed. (Good option for new prescriptions) |
$10 |
$30 |
$45 |
| Home Delivery Pharmacy: Up to a 90-day supply*. Refills allowed as prescribed Best option for maintenance medication) |
$20 |
$75 |
$112.50 |
Generic Drugs are medications sold under a standard name that by law must have the same active ingredients and are subject to the same U.S. Food and Drug Administration (FDA) standards for quality, strength and purity as their brand name counterpart. Generic drugs usually cost less than brand name drugs.
Preferred Drugs are a list of brand name medications preferred for their clinical effectiveness and opportunities to help contain participant and plan costs. The list of preferred medications is available on the Medco website (listed at the end of this section).
Non-Preferred Drugs are brand name medications that are not on the Preferred Drug list because there are effective and less expensive alternatives available. These medications require the highest copayments.
If you choose to purchase a Brand Name Drug when there is a less expensive Generic alternative, you must pay the difference between the cost of the Brand Name drug and the Generic drug plus the applicable Generic Copayment. This difference does NOT count toward your $50 annual deductible per person per plan year. Sometimes the cost difference is quite large. Below is an example of how this type of claim would process if you had already met your $50 annual deductible:
$150 Cost of Brand Name Drug
-$55 Less Cost of Generic Equivalent
+$20 Plus Cost of Generic Copayment
$115 Your Payment
The UT SELECT Prescription Drug Plan administered by Medco also offers a small benefit for Out-of-Network pharmacies. You will pay the full cost of your prescription and send a claim form and your receipt to Medco. Your reimbursement will be based on your total cost, minus the UT discount, the applicable annual deductible and copayment. You will be responsible for the amount above the UT contracted rate.
To help you make the most of your prescription benefit program, UT SELECT provides you and your family the generic substitution program. Generic substitution is the process of substituting the lower cost generic equivalent drug in place of the more expensive brand name medication. Generic substitution is encouraged by pharmacists, plan sponsors, and is provided for by Texas State Law to lower prescription drug costs. The State of Texas has strict guidelines that govern generic substitution. A pharmacist may substitute a prescription issued by a prescriber if the generic product costs the patient less than the prescribed drug product, the patient does not refuse the substitution, and the prescriber does not prohibit substitution. For written prescriptions, a pharmacist may substitute a generically equivalent drug for the brand prescribed unless the prescriber writes in his/her own handwriting the words "Brand Necessary" or "Brand Medically Necessary" on the face of the prescription. For verbal prescriptions, the prescriber or agent may prohibit substitution by specifying "brand necessary" or "brand medically necessary." The pharmacists must note any substitution instructions on the file copy of the prescription drug order. If the prescriber or prescriber’s agent does not clearly indicate that the brand name is medically necessary, the pharmacist may substitute a generically equivalent drug product.
When select non-preferred drugs are prescribed, a specially trained Medco pharmacist in one of Medco's call centers contacts the prescribing physician by telephone or fax. This communication aims to educate the physician on the UT SELECT benefit and specifically to seek conversion to a preferred alternative. All non-preferred drugs identified for interchange are specifically assigned one or more preferred alternatives. Medco's independent Pharmacy and Therapeutics committee must approve all interchange medications. Medco also uses the formulary interchange program to alert prescribing physicians of instances where the prescribed drug may result in an adverse event for the patient (drug-drug, drug-disease, drug allergy complications), and to work collaboratively with the physician to identify clinically appropriate alternative drug therapy options.
The following is a list of how the 25 most purchased drugs are classified by Medco.
| Rank |
Drug Name |
Drug Status |
| 1 |
HYDROCODONE-ACETAMINOPHEN |
Generic |
| 2 |
LIPITOR |
Preferred |
| 3 |
NEXIUM |
Preferred |
| 4 |
LEVOTHYROXINE SODIUM |
Generic |
| 5 |
AZITHROMYCIN |
Generic |
| 6 |
LISINOPRIL |
Generic |
| 7 |
HYDROCHLOROTHIAZIDE |
Generic |
| 8 |
AMOXICILLIN |
Generic |
| 9 |
SIMVASTATIN |
Generic |
| 10 |
SYNTHROID |
Generic |
| 11 |
SINGULAIR |
Preferred |
| 12 |
METFORMIN HCL |
Generic |
| 13
|
FEXOFENADINE HCL |
Generic |
| 14 |
SERTRALINE HCL |
Generic |
| 15 |
LEXAPRO |
Non-Preferred |
| 16 |
FLUTICASONE PROPIONATE |
Generic |
| 17 |
ATENOLOL |
Generic |
| 18 |
ALPRAZOLAM |
Generic |
| 19 |
VYTORIN |
Preferred |
| 20 |
AMLODIPINE BESYLATE |
Generic |
| 21 |
TRIAMTERENE-HCTZ |
Generic |
| 22 |
TOPROL XL |
Preferred |
| 23 |
METOPROLOL SUCCINATE |
Generic |
| 24 |
LEVAQUIN |
Preferred |
| 25 |
FUROSEMIDE |
Generic |
Preferred/Non-Preferred classifications are subject to change during quarterly pharmaceutical review.
Medco Preferred Drug Step Therapy Program
Preferred Drug Step Therapy is a program that promotes Generic and Preferred brand medications as first line therapy. Therapeutically equivalent Generic or Preferred brands are required before non-Preferred drugs unless the physician provides clinical support for the Non-Preferred drug. This program focuses on prescriptions written for the following medications:
- Prevacid
- Aciphex
- Zegerid
- Protonix
- Prilosec 40mg
- Ambien CR
- Lunesta
- Rozerem
- Lexapro (new users only)
- Luvox CR (new users only)
- Effexor XR (new users only)
- Pristiq (new users only)
Member Benefits of the Step Therapy Program
- You lower your out-of-pocket cost by using the over-the-counter, Generic, or Preferred brand.
- Your physician must approve any change or provide clinical explanation for the Non-Preferred drug.
Medications requiring authorization prior to initial prescription
(Contact Medco to request a Traditional Prior Authorization):
- Human Growth Hormones: Protropin, Humatrope, Geref, Genotropin, Norditropin, Nutropin, Saizen, Serostim
- Hormone Agents: Crinone 8%, Lupron, Factrel, Lutrepulse, Synarel
- Immune Globulins: Gamimune, Gammagard, Gammar-IV, Sandoglobulin, Venoglobulin
- Psoriasis Agents: Amevive, Raptiva
- Anti-Obesity Agents: Xenical, Meridia, Tenuate & generics, phentermine
- Asthma: Xolair
- Respiratory Syncytial Virus (RSV) therapy: Synagis, RespiGam
- Cancer Therapy: Iressa, Gleevec, Tarceva, Avastin, Dacogen, Temodar, Erbitux, Nexavar, Sprycel, Sutent, Tasigna, Torisel, Tykerb, Vectibix, Vidaza, Zolinza
- Irritable Bowel Syndrome (IBS): Lotronex
- Acromegaly: Somavert
- Interferons: Actimmune, Infergen, Roferon, Intron, Intron-A, Alferon, Rebetol, Rebetron, PEG-Intron, Pegasys
- Erythroid Stimulants: Epogen, Procrit, Aranesp
- Multiple Sclerosis Agents: Betaseron, Avonex, Rebif, Copaxone
- Myeloid Stimulants: Neupogen, Leukine, Neulasta
- Platelet Growth Factor: Neumega
- Immunomodulatory Agents: Thalomid, Revlimid
- Acne & other dermatologicals: Accutane, Retin-A, Avita for ages 36 and over
- Antiemetics: Anzemet, Cesamet, Emend, Kytril, ondansetron, Zofran
- Paroxysmal Nocturnal Hemoglobinuria (PNH) Agents: Soliris
- Phenylketonuria (PKU) Agents: Kuvan
- Cystic Fibrosis Agents: Pulmozyme
- Gaucher’s Disease: Zavesca
- Miscellaneous Hormones: Sensipar
- Pulmonary Arterial Hypertension (PAH) Agents: Tracleer, Ventavis, Revatio
- Antiparkinsonism Agents: Apokyn
Medications requiring authorization to obtain additional supplies
(Contact Medco to request a Smart Prior Authorization):
- Onychomycosis Therapy: Sporanox, Lamisil, Diflucan, fluconazole
- Anti-Virals: Acyclovir, Famvir, Valtrex, Zovirax
- Pain Management: Actiq, Fentora, Euflexxa, Hyalgan, Orthovisc, Supartz, Synvisc
- Rheumatoid Arthritis: Humira, Enbrel
- Hypnotic Agents: Ambien, Ambien CR, Lunesta, Rozerem, Sonata
- Antiemetics: Anzemet, Cesamet, Emend, Kytril, ondansetron, Zofran
- Asthma: Xolair
- Cancer Therapy: Avastin, Gleevec, Erbitux, Nexavar, Sprycel, Sutent, Tarceva, Tasigna, Tykerb, Vidaza, Zolinza
- Cystic Fibrosis Agents: TOBI
- Psoriasis Agents: Amevive, Raptiva
- Gaucher’s Disease: Zavesca
- Miscellaneous Hormones: Sensipar
- Pulmonary Arterial Hypertension (PAH) Agents: Letairis, Ventavis, Revatio
- Immunomodulatory Agents: Revlimid
- Multiple Sclerosis Agents: Tysabri
- Antiparkinsonism Agents: Apokyn
Medications requiring authorization based on drug history
(Contact Medco to see if authorization is required)
- Pain Management: Actiq, Fentora
- Antidepressant Therapy: Wellbutrin SR, Bupropion SR
- Rheumatoid Arthritis: Enbrel, Humira, Kineret, Arava, Remicade
- Cystic Fibrosis Agents: TOBI
- Pulmonary Arterial Hypertension (PAH) Agents: Letairis
- Dermatological Agents: Elidel, Protopic
- Interferons: Copegus, Rebetol
- Rheumatoid Arthritis: Orencia, Rituxan
Personalized Medicine Program
Your prescription drug coverage includes the Personalized Medicine Program, a program that incorporates genetic testing to optimize prescription drug therapies for certain conditions. The conditions, drugs and testing covered by the program will change from time to time as new genetic tests become available and are included in the program. As of the date of this SPD, the Personalized Medicine Program is available to participants meeting a specified clinical profile who are prescribed Tamoxifen for breast cancer or Warfarin. The most up to date information on the conditions and drugs covered by the program can be accessed online at www.medco.com or by calling a Medco customer service representative at 1-800-818-0155.
If you are a qualified participant, additional services are available to you through the Personalized Medicine Program at no additional cost. The Personalized Medicine Program includes: (i) access to certain specified genetic tests administered and analyzed by one of several designated clinical laboratories; and (ii) a clinical program that includes the interpretation of test results and consultation with your prescriber by a representative of Medco trained specifically in genetic testing. Medco will also offer on-going outreach and education to physicians and patients when appropriate.
When you qualify, Medco will contact you and/or your physician to enroll you in the program. With approval from your physician, the clinical laboratory will facilitate the processing of a genetic test and share the results of the test with your physician and Medco. The results of the genetic test are for informational purposes only, any dosing or medication changes remain in the sole discretion of your physician. Your participation is voluntary and if you decide to participate, Medco will facilitate your coverage under the Program.
My Rx Choices
An industry-leading prescription savings program, My Rx Choices is offered as an enhancement to your benefit plan allowing you to
- View a single presentation of medications with potential savings;
- Comparison-shop for available lower-cost alternatives;
- Use the “With-a-click” option to have Medco contact physicians on members’ behalf to request approval for equivalent conversions received through mail; and
- Review options with your doctor and request prescriptions for lower-cost alternatives.
Accessed via the web (www.medcohealth.com) or through the toll-free service line (1-800-818-0155), My Rx Choices features include
- Personal assessment of cost-saving opportunities;
- Best-value alternatives based upon greatest cost savings to you presented in order from highest value to you;
- The most accurate, actionable drug compare pricing information available in the industry today; and
- Brand-to-generic and retail-to-mail compare options.
You may read additional information about pharmacy plan features and exclusions in the
Medical Plan certificate, also available from your institution Benefits Office.
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