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Insurance FAQs Health

Prescription Drugs

  • The formulary for your health plan provides a list of medications that a team of health care specialists have approved. Your doctor will write a prescription based on your medical needs, but the formulary provides him with recommendations from the pharmacist and physician team. An effective formulary system provides a medication safety feature. When drugs and administration methods are systematically included (or deleted) in a controlled drug formulary, there are a number of benefits. For instance, each new drug added undergoes a peer review process that uncovers any safety concerns with the drug. Also, when drugs are systematically added to the formulary, there is adequate time to educate the staff before the drug is used. An organized formulary also ensures that the number and variety of drugs is kept to an effective minimum. There are approximately 13,000 prescription drugs on the market today and several drugs can often be used to treat the same condition. A formulary, based on safety and cost considerations, helps to limit the drugs recommended by your plan's health care professionals.
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  • When a drug patent expires other companies may produce a generic version of the brand name drug. A generic medication, also approved by the FDA, is basically a copy of the brand name drug and is marketed under its chemical name. A generic drug may have a different color or shape than its brand name counterpart, but it must have the same active ingredients, strength, and dosage form (i.e., pill, liquid, or injection), and provide the same effectiveness and safety as its brand name counterpart.
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  • A brand name drug is approved by the Food and Drug Administration (FDA), and is supplied by one company (the pharmaceutical manufacturer). The drug is protected by a patent and is marketed under the manufacturer's brand name.
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  • Contact your health plan directly for this information.
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  • Yes. Generic drugs are less expensive than brand name products, and so the amount you pay as part of your prescription drug cost-sharing is less than what you pay for brand names. In addition, most plans charge you a lower copay if you use generic drugs.
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  • No. Approximately half of all drugs on the market have generic versions.
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  • Valium is a brand name drug whose generic counterpart is Diazepam. On the other hand, Amoxicillin is a generic drug of the brand drug Trimox.
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  • A formulary is a list of both generic and brand name drugs that are preferred by your health plan. Often, many drugs on the market produce the same results equally well. Health plans will choose formulary drugs that are just as safe and effective as the alternatives but cost less. A team of pharmacists and physicians meet to review the formulary and make changes as necessary.
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  • Cost increases are due to several factors.
    • Pharmaceutical companies are producing a record number of medications and many carry a high price tag. It cost an average of $500 million to discover and develop one new medicine, and it takes an average of 12 to 15 years to bring a new medicine from the laboratory to the pharmacy shelf.
    • Drugs are used more and more to avert illness and hospital admissions. Asthma, heart disease, and ulcers are among conditions successfully being treated with drugs.
    • The over-age 65 population is growing larger and living longer and this leads to an increase in the utilization of prescription drugs.
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  • You will usually pay more for a non-formulary drug when a formulary version is available.
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  • Each state has a law that allows pharmacists to substitute less expensive generic drugs for many brand names. However, if your doctor specifies that a brand name must be dispensed, then the pharmacist may not substitute the generic. Sometimes an acceptable generic is available that your doctor may not be aware of. In this case, your pharmacist may be able to consult with your doctor to suggest an effective medication that costs less.
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  • Every day, millions of Americans rely on medications to feel better and get well, but it is not always easy to take them correctly. Not taking medications properly can prevent you from getting well as fast as you can. Also, taking medicine with certain foods, alcohol, dietary/herbal supplements, or other medicines might cause a dangerous reaction, or it might stop your medicine from working as well as it should. Here are some questions that can help you get the information you need to use your medicines properly. If the answers seem complicated or confusing, ask again!
    1. What is the name of the medicine and what is it supposed to do? Is this the brand name or the generic name?
    2. How and when do I take it -- and for how long?
    3. What foods, drinks, other medicines, dietary supplements, or activities should I avoid while taking this medicine?
    4. When should I expect the medicine to begin to work, and how will I know if it is working? Are there any tests required with this medicine (for example, to check liver or kidney function)?
    5. Are there any side effects, what are they, and what do I do if they occur?
    6. Will this medicine work safely with the other prescription and nonprescription medicines I am taking?
    7. Can I get a refill? When?
    8. How should I store this medicine?
    9. Is there any written information available about the medicine? Is it available in large print or a language other than English?
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  • There is no evidence of this. The FDA monitors reports of adverse drug reactions and has found no difference in the rates between generic and brand name drugs.
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  • Yes. The FDA requires that all drugs be safe and effective and that their benefits outweigh their risks. Since generics use the same active ingredients and are shown to work the same way in the body, they have the same risks and benefits as their brand name counterparts.
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  • Yes. OPM does not prohibit FEHB members from participating in pharmacy-sponsored incentive or pharmaceutical company co-pay reimbursement programs, and we are unaware of any Federal laws restricting participation.  Enrollees in other Federal Programs such as Medicare and Medicaid are statutorily prohibited from participating in pharmacy incentive programs under section 1320a-7b of title 42, United States Code (the Anti-Kickback Act).  However, the FEHB Program is exempt from the application of this provision. OPM does not have authority over promotional incentive programs retail pharmacies choose to offer its customers, and OPM cannot direct retail pharmacies to provide the incentives to FEHB Program members. We are working with FEHB Program plans to remove any restrictions.
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