What is EfficientRX?

Lowering Costs with EfficientRx and Blue Dimensions 

EfficientRx™ is a new prescription drug formulary BCBSMT is using to reduce costs for our members and groups while providing safe, clinically sound, effective care.  The goal of EfficientRx is to decrease costs by increasing utilization of medications that provide the most value without sacrificing health outcomes.  The most effective means to accomplish this is by encouraging the use of generic drugs.

 

Generic drugs are safe and effective and cost less than brand-name drugs.  Many generic drugs are former brand-name drugs whose marketing-exclusivity period has expired.  Generic drugs meet the same high standards as brand-name drugs, and both must be approved by the FDA.

 

Employers who choose the EfficientRx formulary will typically see significant and immediate savings over the TraditionalRx formulary—without a reduction in the quality of care their employees receive.  Members will also see immediate savings by using or switching to a clinically appropriate generic medication because the copayments are much less than for the brand counterpart.

The EfficientRx formulary consists of nearly all approved generics plus those brand-name drugs necessary to ensure clinically complete coverage.  Brand-name drugs are included only when a generic is not available to treat a specific medical condition or the brand-name drug offers a significant advantage over available generic drugs.  Also, certain drugs with significant safety or efficacy concerns are excluded from the EfficientRx formulary.

The EfficientRx formulary and a list of noncovered drugs are available at www.bcbsmt.com.

 

EAM Full-Card Prescription Drug Benefit on CMM Plans

  • $150 Individual Deductible (waived on generics)
  • Retail Copayment/Coinsurance (34-day supply):  Generics – $8; Brand Formulary – $40;
  • Brand Nonformulary – 60% up to a maximum of $200
  • Mail-Order Copayment/Coinsurance (90-day supply):  Generics – $16; Brand Formulary – $80;
  • Brand Nonformulary – 60% up to a maximum of $400
  • Specialty Pharmaceuticals (30-day supply):  Formulary – $100; Brand Nonformulary – $200
  • Mandatory Generic – Member is responsible for the difference between the cost of the brand‑name drug and its generic plus the generic copayment when they choose the brand name over the generic, even if the prescribing physician indicates “dispense as written” on the prescription.
  • Utilization Management Programs Apply (Prior Authorizations, Step Therapy and Quantity Limits)


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    For groups choosing to integrate their pharmacy claims into their medical benefit, the EfficientRx formulary will still be applied.

Brand Drugs and Generic Drugs

Classification

Prescription drugs are classified as either: (1) brand drug, or (2) generic drug.  The brand/generic classification is linked to the copayment level or tier.  BCBSMT uses the brand or generic status provided by a nationally recognized company providing drug product information.  The brand/generic status for a specific drug/specific marketer can sometimes change over the life of a product in the marketplace and change from brand to generic (or) generic to brand.  Such changes might change your copayment share.  Brand drug or generic drug status is never based upon a product having a trade name.  Generic drugs often have trade names.

Generic Drugs

BCBSMT encourages the use of generic drugs as a way to provide high-quality, cost-effective care.  Generic drugs are safe, effective, and cost less than brand-name drugs.  Members will likely pay a lower copayment or coinsurance for a generic drug.

To encourage the use of generic drugs, Tier 2 brand drugs typically move to Tier 3 after a generic version becomes available.  If a physician indicates “Dispense As Written” (DAW – 1 or equivalent designation), or if the patient insists upon a brand product for a drug, the patient may be required to pay the cost difference between the brand and generic products in addition to the applicable copayment.  Specifics can be found in the member contract.

Specialty Medications

Specialty medications have different copayments.  The Triessent Specialty Program must be used to fill certain specialty medications just as they have in the past.  The full Triessent Specialty Pharmacy list is also available at www.bcbsmt.com.

Frequently Asked Questions about Generics

  • Are generics as good as brand-name drugs?  Both brand-name and generic drugs must be approved by the FDA.  Generic drugs meet the same high standards as brand-name drugs.
  • Why should I take generic drugs rather than brand-name drugs?  We must all do our part to make health care affordable.  One way is to be wise buyers of drugs.  Generic drugs provide the same effectiveness and safety as their brand-name counterparts, but for a lower cost.  Lower costs generally mean lower copayments for members.  Generic drugs also save money for your health plan, so premiums can be kept as low as possible.
  • How can I take advantage of lower-cost generics?  Ask your pharmacist for a generic drug whenever available.  Also, talk with your doctor or other provider about prescribing generic drugs.  Most drug classes include some generic drugs.

EfficientRx is a registered trademark of Prime Therapeutics LLC.