Oxford Changes Tier 3 Prescription Drug Rules for NY Small Groups

As drug costs continue to rise, carriers are creating innovative ways for members to maintain affordable access to a variety of medications. Oxfords Select Designated Pharmacy Program, for example, focuses on providing members with access to lower cost alternatives to a select number of Tier 3 (high-cost) medications. This program will be implemented for Oxford fully insured New York small groups (2-50 lives) on January 1, 2011. The program does not apply to Healthy NY plans, and is optional for self-funded groups. 

About the program  Members of the program are required to choose one of three cost-saving options to continue to receive medications at the in-network benefit level:              

  • Option 1: Switch to a lower-cost medication and save
  • Option 2: Fill the prescription through the Mail-Order Pharmacy and save
  • Option 3: Do both to save 

Members are allowed two “grace” fills of their current medication at the retail pharmacy before they must select a new option. If a member chooses to continue filling a Tier 3 medication at the local retail pharmacy after the second grace fill, the member will pay the full cost of the medication, as benefits are not payable under the plan.

 Medications included in the program The targeted medications and products listed below, all in Tier 3, represent 2% of all retail prescriptions. The majority of these have multiple, lower-cost alternatives.

Medications

Lyrica, Symbicort, Avodart, Uroxatral, Lexapro, Atacand, Atacand HCT, Avapro, Avalide, Asacol, Asacol HD, Axert, Frova, Maxalt, Maxalt MLT, Zomig, Zomig ZMT, Toviaz and Detrol.

All employers will receive a letter from Oxford about the Select Designated Pharmacy Program as well as all members that are currently taking these medications. Members will also receive an outgoing call from Oxford, and point -of-sale messaging at the retail pharamacy to help them understand their options for savings.

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