Three-Tier Prescription Copayment
Q & A

1. What is a three-tier prescription copayment structure?
In addition to generic and brand drug copayments currently offered under the prescription drug program, a new third level copayment is being introduced for preferred brand drugs. The new three-tier prescription copayment plan provides you with the same access to generic and brand drugs that are currently available to you under the plan.
Medications in a 3-tier benefit structure are divided into 3 groups. All generic drugs are in the 1st tier copayment; certain brand drugs, including Preferred Brands, are in the 2nd tier copayment; and Non-Preferred Brands are in the 3rd tier copayment. There are generic and/or Preferred Brand alternatives available for Non-Preferred Brands. You should discuss the possibility of being prescribed a Preferred Brand or generic with your physician, if appropriate. Your doctor always has the final decision on drug selection. If your doctor prescribes a Non-Preferred Brand even after you have explained your preference for a Preferred Brand or generic, it will still be covered but at the higher copayment. Please note that commonly prescribed 1st and 2nd tier drugs are listed on the preferred drug list for your reference.

2. What is the Performance Drug List (PDL) and what is a preferred drug?
The PDL is a list of commonly prescribed drugs in select drug classes, or grouping of drugs that are used to treat the same condition. There are preferred brand drugs as well as generic drugs listed on the PDL. The drugs listed on the PDL are considered preferred drug choices as they provide the greatest economic value in the drug class. It is important to note that preferred medications are not chosen for inclusion on the PDL based on price alone; they are selected based on comparable clinical efficacy to other products in the same drug classes. The PDL undergoes a rigorous clinical and economic review annually. Medical specialists (physicians and pharmacists) evaluate any proposed changes to ensure they are consistent with the most recent and relevant clinical findings.

3. Why is California's Valued Trust implementing this new three-tiered prescription copayment structure?
For the past several years, drug spending has grown more rapidly than any other component of health care in the United States. All indications are that double-digit increases will continue for at least the next three to five years. This new copayment structure is intended to help offset the steep increases in the drug program by maintaining a reasonable cost share between CVT and plan participants.

4. Why is my brand drug considered Non-Preferred and at the 3rd Tier Copay?
The PDL lists clinically appropriate medications which are the most cost-effective choices in a given drug class. Non-preferred medications have preferred lower cost clinical alternatives on the PDL, and if you and your physician agree that a preferred drug is appropriate for you, CVT is passing on the savings that these PDL drugs represent by lowering your copay.

5. What if my doctor doesn't agree that a PDL alternative is appropriate in place of the brand drug that I'm currently prescribed?
You should remain on the drug that your doctor feels is appropriate for your condition. If you or your doctors feel that a preferred medication is not appropriate, you still have coverage for that drug but you will pay the higher brand copayment.

6. How often is the PDL updated?
The PDL undergoes a rigorous clinical and economic review annually. Medical specialists (physicians and pharmacists) evaluate any proposed changes to ensure they are consistent with the most recent and relevant clinical findings. The PDL decisions from the annual review process are implemented on Jan. 1 of each year.

7. What happens if a brand drug I am currently taking is no longer included on the PDL?
Although the PDL does not undergo extensive review during the year, significant events in the marketplace may necessitate an interim change. Though rare, these could occur at the beginning of any calendar quarter. In the instance where a drug has been withdrawn from the market, the drug would be removed from the PDL immediately. When a brand drug is removed from the PDL, whether due to an interim change or the annual update, Caremark sends a notification to the members currently using that drug. This notification informs the member of the change and provides alternative drug name(s) at the lower copay.

8. Can I get a copy of the AdvancePCS PDL and will changes to the PDL be sent to me automatically when it is updated?
The PDL is available online at the Caremark Web site www.caremark.com. You may also call Caremark member services at (800) 966-5772. The PDL is not distributed automatically to members when updated; to obtain the most recent copy, visit the Caremark Web site or call Caremark member services.

9. What is a generic drug and how do I know a generic drug is as good as the brand drug?
Once the patent has expired on a brand drug, a generic drug may typically be produced. A generic drug must have the same active ingredients, meet the same standards and produce the same clinical results as the brand name prescription drug. Every generic version of a brand drug must be reviewed, tested and approved by the FDA.

10. How can I have my brand drug added to the PDL?
The PDL lists clinically appropriate medications which are the most cost effective in a given drug class. Caremark reviews all clinical and economic factors before a drug is added or removed from the PDL. Given this, plan member requests for adding drugs to the PDL cannot be considered.

11. What if I forget to ask my doctor about selecting a drug from the PDL and I take my prescription for a brand drug to the pharmacy?
If you take your first prescription or refill to an Caremark Network pharmacy, the pharmacist will receive an electronic alert that a preferred alternative exists for your drug if your drug class is on the PDL. If you agree to change to the preferred drug, the pharmacist will call your doctor for approval. If your doctor approves, you'll get the preferred drug. If the pharmacist can't reach your doctor when the prescription is initially filled, he may dispense the non-preferred drug and continue to try to reach your doctor for approval to dispense the preferred drug on the next refill.

12. My pharmacist told me that my drug is not covered, but it was always covered before.
Your pharmacist may have misread the message that was provided letting him know that a preferred alternative exists for your drug. If this happens, you should let them know that the drug is still covered, and that CVT is now participating in the voluntary Caremark PerformanceRx program. The pharmacist can also contact the Caremark Pharmacy Help Desk at 800-345-5413 for further assistance.

13. How does the PDL apply to Mail Order?
Mail Order service offers a 90-day drug supply and also has the new three-tiered copayment structure.