Public Employee Press

Generics to be mandatory for cholesterol-lowering drugs

Brand-name statins will no longer be covered without prior authorization

Beginning April 1, the DC 37 Health and Security Plan's prescription drug benefit will require participants to use generic cholesterol-lowering drugs unless they obtain prior authorization to use a brand-name medication.

Members and retirees prescribed cholesterol-lowering medication for the first time will be required to participate in a step therapy program. The program requires participants to start out with a generic and receive prior authorization from the DC 37 Health and Security Plan's medical consultant to use a brand-name medication.

Deeply concerned about the relentless increase in the cost of prescription drugs, the plan's trustees in January 2010 adopted a zero co-pay for generic statins to encourage participants to use generic versions. Generic drugs are as effective as brand-name drugs, according to medical and clinical evidence, and they are put through the same rigorous U.S. Food and Drug Administration approval process.

Unfortunately, the zero co-pay inducement for generics failed to convince enough participants to switch.

So, the trustees decided to make cholesterol-lowering generics mandatory in addition to implementing the step therapy and prior authorization protocols for brand-name statins. The trustees also decided to subject all brand-name statin prescriptions to the plan's tier 3 (highest) co-pay of $35 for a monthly supply of drugs.

In 2010, prescription drugs ate up 75 percent of the DC 37 Health and Security Plan's entire budget for benefits, which include death, dental, disability, legal services and optical benefits.

Participants who are already taking a brand-name statin and wish to continue must provide the plan with "contemporaneous medical records" (CMRs) from their physician that specify the medical reasons they cannot take a generic. If the plan's medical consultant denies the brand-name medication, participants have the right to appeal.

Members whose appeals are denied may take brand-name statins, but they will have to pay the current ancillary charge of $145 - the difference between the ingredient costs of the brand-name and generic statins - plus the plan's $35 tier 3 co-pay.

Participants who received prior authorization from the medical consultant to take a brand-name statin will only pay the tier 3 co-pay for nonpreferred drugs. After Jan. 1, participants who are now taking a brand-name statin will be allowed one 90-day refill. But as of April 1, the plan will only cover generic statins if they receive prior authorization. The last time for obtaining a 30-day renewal of a current brand-name prescription is March 31.