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.


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.

New Law Protects Consumers From Discriminatory RX Copayments

Senator Kenneth P. LaValle announced that legislation which prevents health insurance plans from creating new “specialty tiers” to dramatically increase the copayments that consumers pay has been signed into law.  The law becomes effective October 31, 2010 and will protect people suffering from chronic or life threatening illnesses from discriminatory copayments.

According to Senator LaValle, several states across the country have begun adding to their prescription copayment structure to include additional tiers, or “specialty tiers,” for the most expensive medications.  These “specialty tiers” assign a percentage of the cost of a medication as a copayment instead of the traditional set dollar amounts used for “generic,” brand-name preferred,” and “brand name non-preferred” drugs.    In states where this has happened, the copayments have typically been 20% to 35% of the cost of the medication.

“The creation of ‘specialty tiers’ for prescription copayments could have a debilitating financial impact on people who take medications on a daily basis, particularly those who are suffering from serious illnesses,” said Senator LaValle.  “I am pleased to have supported this new law to protect people in need of prescription medications from suffering the possibility of financial ruin on top of coping with their illness.”

Discounted Prescription Drugs for Suffolk County Residents

The Suffolk SCRIPTS (Suffolk County Initiative to Provide Taxpayer Savings) Program allows Suffolk County residents to save an average of 20 percent off the retail price of their personal medications. While SCRIPTS is not an insurance plan in itself, this prescription discount card can help bridge the financial gap for all Suffolk County residents– even those with personal insurance plans.  Best of all, the Suffolk SCRIPTS card is free.

 The Suffolk SCRIPTS card is accepted at over 300 pharmacies within the County, at more than 57,000 pharmacies nationwide, and is available through mail service. It carries no age or income restrictions, and no limits on how often it can be used. You and your family may freely use this card at any time, even when your prescription is not covered by your personal insurance plan. Simply present the discount card at a participating retail pharmacy and start saving on many of your prescription drugs. To find out where to pick-up a card of your own, please call toll-free 1-877-321-2652.

Flexible Spending Account Substantiation Mandate

Beginning July 1, 2009, IRS Notice 2008-104 mandated the auto-substantiation of Medical FSA and Health Reimbursements Accounts debit card transactions at pharmacies. 

Auto substantiation refers to the use of an Inventory Information Approval System (IIAS) to isolate eligible healthcare expenses. Eligible healthcare items purchased at a pharmacy that have implemented an IIAS will be substantiated at the point-of-service expenses. The IRS did give merchants a grace period thru December 31, 2009 to comply with the Inventory Information Approval System (IIAS).

This requirement may feel burdensome for employees using the debit cards at pharmacies that haven’t implemented the IIAS system, but will in the long run reduced the dreaded “pay and chase” events for third party administrators, will decrease participant fraud in your programs and reduce financial risk.

Two Levels of IIAS Auto-Substantiation

Healthcare Eligible Total (HET) Each card terminal at an IIAS merchant will “break down” the items purchased and categorize the expense as either healthcare eligible or non-healthcare.  The Healthcare Total is defined as all IRS Section 213(d) expenses (all Medical FSA eligible items).  All non-healthcare products will be declined at the point of sale and will require the customer to use a different form of payment other than the Flex debit card.

Prescription Subtotal (Rx-Only) many pharmacies will implement a higher level of IIAS that will separate the HET into two categories: Medical Over-the-Counter (OTC) and Prescription Rx. Even though this higher-level IIAS system is not mandated, it will facilitate administration for many prescription-only HRA plans.

If your pharmacy is hasn’t implemented the IIAS system your debit card will not be accepted.  A special interest group has been formed for IIAS Standard.  I have attached a list of Compliant IIAS Merchants click here.

Money Saving Tips on Brand Name Medications

The next time your doctor prescribes a name brand medication it may be worth checking online or with your local pharmacy to see if there is any special money saving offers available.  Many of these brand name drugs have their own dedicated websites that will provide  specific information to obtain savings.  

Provided below is a SAMPLE of medications that have special money saving offers.  This is not an all inclusive listing, so if you do not see a particular medication listed you may want to research the medication online.

Check here to see the sample Brand Name money savings list.

Stores Offering Free Antibiotics and Updated $4 Generic Drug Deals

NJ Prescription Drug Price Registry

The NJ Prescription Drug Registry will help consumers compare retail prices charged by pharmacies for the most frequently prescribed prescription drugs. By comparing prices here, consumers can see what a pharmacy has reported to the state that it charged for a specific Rx. You will find that prices for the exact medication will be different from pharmacy to pharmacy and from town to town. To use this registry click here, this link will also be on the right side of my blog titled NJ Prescription Drug Registry. New York and Connecticut have a similar site called Prescription Drug Prices in New York State and CT Attorney General’s Prescription Drug Page.



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