Open Season Report
2016 FEHBP Prescription Drug Guide
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n the Federal Employees Health Benefits Program, prescriptions can be filled by health plans through the plan’s preferred retail pharmacies, nonpreferred retail pharmacies and the plan’s mail order service. The plans charge coinsurance and/ or co-payments for prescription drugs when they are purchased through any of these sources. Some plans provide prescription drug plan benefits even if the plan’s annual deductible is not met. Other plans may have a specific annual deductible that must be met before the plan begins to pay prescription drug benefits. Health plans will substitute avail-
able generic equivalent drugs for brand name drugs for prescriptions submitted to local pharmacies and mail order services, unless the prescribing physician indicates that the patient is to receive only the brand name medication. To keep prescription drug benefit costs down for the plans, some are reducing out-of-pocket costs for generic drugs and raising them for brand name drugs. This will make prescription drugs more costly for enrollees needing life-saving and life-extending medications, which are usually brand name specialty drugs. You also will see that some plans have capped the yearly amount of out-of-pocket expenses
for prescription drugs to keep enrollees who need the expensive brand name drugs – sometimes called specialty drugs – from possible financial hardship. Enrollees covered by Medicare Part A and Part B may note that some plans waive their own deductibles, coinsurance and copayments for hospital and medical services. These waivers do not apply to the prescription drug co-payments and/or coinsurance. Some plans will charge lower coinsurance and co-payment rates for enrollees who are covered by Medicare Part A and Part B. In addition, there are some plans that charge Medicare enroll-
Prescription drug benefits for selected FEHBP plans
Plan Retail Pharmacy / Network R
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APWU - High
Generic: $10 Brand name: Preferred 25% / Nonpreferred: 40% Specialty drugs: Generic: 25% / Brand name: Preferred: 25% / Nonpreferred: 40%
Blue Cross and Blue Shield - Standard
Generic: 20% of plan allowance (15% if you have Medicare) Brand name: Preferred: 30% of plan allowance / Nonpreferred: 45% of plan allowance
GEHA - Standard
Generic: Lesser of $10 or pharmacy’s usual & customary cost Brand name: 50% up to a max of $200
MHBP - Standard
Electronic: Generic: $5 co-pay per presc. Brand name: Preferred: 30% of plan allowance (25% if enrolled in Medicare B) + any difference between plan allowance and cost of generic unless exception obtained, limited to $200 per presc. / Nonpreferred: 50% of plan allowance + any difference between plan allowance and cost of generic unless exception obtained, limited to $200 per presc. Paper: See Non-Network Retail
NALC - High
Generic: 20% of cost Brand name: Formulary: 30% of cost / nonformulary: 45% of cost (If enrolled in Medicare: NALC Senior Antibiotic generic: $0; generic: 10% of cost; formulary brand: 20% of cost)
SAMBA - Standard
Generic: $8 Brand name: Preferred: 30% of plan allowance / nonpreferred: 40% of plan allowance
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