Mandatory Generic Program “Generics First” For Drugs That Treat High Cholesterol, High Blood Pressure and Acid Reflux

Effective July 1, 2009

In an effort to control the Health Fund’s rapidly rising expenditures for drugs that treat high cholesterol, high blood pressure and acid reflux, while at the same time assuring that participants will have access to drugs that treat these serious conditions, the Trustees have decided to adopt a mandatory “generics first” program for drugs in these classes. Under this program, the Fund will pay only for generic drugs in these classes (unless the medical necessity for a brand name drug has been established by a participant’s physician). This plan change was effective for all prescriptions written or renewed on or after July 1 2009. It is estimated that the Fund will save 20% to 35% yearly on those classes of drugs as a result of implementing this plan change. The percentage savings for members can be expected to exceed that 20-35% range (through a combination of lower copays and lower drug costs).

This benefit change means that prescriptions written for non-generic versions of these classes of drugs, will, in most cases, not be paid for by the Fund, unless you doctor establishes the medical necessity of using such non-generic drug.

Generic drugs in these classes will be paid for under the generic drug benefit currently provided by the Fund (e.g., after the $100 annual deductible has been satisfied, prescriptions filled at a network pharmacy will be paid for in full after a copay of $10 or 20% of the cost of the drug, whichever is greater, has been satisfied). Members taking any other type of drug (that is, all drugs outside of these categories) are not affected by this change, neither are members who are already taking generic versions of the three aforementioned categories of drugs.

Background

Over the past decade, the Health Fund, and the US in general, have seen an explosion in the use of what might be termed “risk reducing” drugs – drugs that treat high cholesterol (Statins), high blood pressure (Angiotensin Converting Enzyme Inhibitors (ACEI)/Angiotensin Receptor Blockers (ARB)) and acid reflux (Proton Pump Inhibitors (PPI)). These drugs can be termed risk reducing because they are largely used to control conditions that increase the risk of serious illnesses or incidents (e.g., heart attacks, strokes, esophageal cancer) even though the conditions they control are often not experienced in a negative way by the patient (patients do not feel high cholesterol or high blood pressure, and may not be terribly troubled by acid reflux, but these conditions can lead to fatal illnesses and incidents). Over the past several years, the Health Fund has spent approximately $700,000 per year (nearly 2% of total Health Fund claims costs) on the above-mentioned categories of risk reducing drugs alone.

There is no doubt that risk reducing drugs can be vital for patients with the conditions they treat, and the growth in their popularity is likely to lead to improved health for millions over the long run. However, it is also true that the popularity of these medications has caused pharmaceutical companies to focus on maximizing their profits on these categories of drugs. Often this means launching a “new and improved” version of a drug that for most patients has few, if any, advantages over existing treatments, but which affords the pharmaceutical companies greater opportunity for profit because these new drugs have patent protection from competitors. Even when drugs lose their patents, drug companies will claim that their “brand name” is superior to the newly available generic versions of the drug, even though the generic is chemically identical to the original (patented), version of the drug (the only real difference may be the binder or color used in manufacturing the drug).

For instance, Nexium may be only marginally better for treating acid reflux than its therapeutic equivalent - generic Prilosec, yet Prilosec costs approximately $50 per 30 day supply, versus $200 for Nexium. Similarly, the generic version of Zocor might cost approximately $15 for a 30 day supply, but the same supply of its brand equivalent Crestor might cost $125. Therefore, when you use brand name drugs instead of generics, you may be unnecessarily increasing the cost of those drugs to you and the Fund by as much as 4 or 7 times, or even more, with no added benefit to you.

What Should I Do If I Think I May Be Affected By The Change?

The first thing to do is to discuss this change in your prescription drug benefits with your doctor. In most cases, it is expected that your doctor will be able to change your current medication(s) to a generic version. That will save both you and the Health Fund money.

Alternatively, if your doctor feels the brand name version of the drug is medically necessary for you, he/she can appeal to CIGNA by contacting them at (800) 244-6224 for a waiver of the generic requirement. Such a waiver can also be granted if you have already tried a generic version of the drug within the past 18 months without success.

The Mandatory Generic program began on July 1, 2009, requiring use of generic versions of ACEI/ARB (for high blood pressure), Statin (for high cholesterol) and PPI (for acid reflux) drugs for all prescriptions filled on or after that date. Only the generics will be reimbursed under the plan (unless the medical necessity for the brand name version has been accepted by CIGNA).

Which Participants Who Are Taking Drugs That Fall Into The Three Categories Mentioned Are Not Affected By The Change ?

Anyone who is currently taking the following medications will not be affected by this change in the Fund’s coverage and need do nothing:

Which Participants Who Are Taking Drugs That Fall Into The Three Categories Mentioned Are Affected By The Change ?

Those who are taking brand name ACE I/ARBs, Statins and PPIs, will be affected. Examples of these drugs are:

What are Generic and Therapeutically Equivalent Drugs?

A generic drug is identical or bioequivalent (rate and extent of absorption is the same) to a brand name drug. It is identical in terms of dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. Although chemically identical to their brand name drug counterparts, generic drugs are typically sold at much lower prices than brands. The Congressional Budget Office has estimated that generic drugs save consumers $8 to $10 billion a year at retail pharmacies. (That does not count the estimated billions saved by hospital use of generics).

Drug companies must submit a drug application to the FDA (and receive its approval) in order to sell a generic product. The application process does not require that animal and clinical research be reported on ingredients or dosage forms already approved for safety and effectiveness. However, to secure gain FDA approval, a generic drug must have:

• The same active ingredients as the original drug (inactive ingredients can vary)

• Identical strength, dosage form, and route of administration

• The same use indications

• Bioequivalency

• Meet the same batch requirements for quality, identity, strength and purity

• Be manufactured under the same strict standards of FDA’s good manufacturing practice regulations required for brand names

A therapeutically equivalent drug is a drug that is in the same clinical classification that can be substituted with the expectation that the substituted product will produce a similar clinical effect with a similar safety profile as the prescribed product.

Is A Generic Drug Available For The Brand Name Drug I’m Taking?

You can find out by going to the CIGNA website at www.cigna.com and, on the “Customer Care” menu at the left, clicking on the “Drug Lists” link. From there, you can key word search your specific drug by entering the name of the drug and clicking on the name of the drug that appears on a the pop-up list, then clicking on “Go”. At that time, the website will show you whether a generic alternative is available for that specific medication. Additionally, you can click on the “Drug Class/Type” link on the right of the results. That will bring up a list of any medications that are therapeutically equivalent to the brand name drug you entered and indicate whether that equivalent is available in a generic version.

This CIGNA web resource applies to all medications you may be taking. If the medication you are searching happens to be one subject to the mandatory generic program, it will have a “ST” designation on the CIGNA website, indicating the product would be subject to Step Therapy (another term for our mandatory generic program). If there is no ST, the brand name may be available under the mandatory generic program even though that drug is generally not covered, because no drug suitable generic is available at that strength. You can also call CIGNA at 1-800-244-6224 and get the same information that is available through their web-site.

What If I Try A Generic Drug And It Does Not Work For Me?

If you try a generic version of a drug and that version does not work well for you, or generates side effects that you did not experience with a brand name drug, you have at least two avenues to explore.

First, you can try another generic. That may well work for you. If it does, you’ll save money and so will the Fund.

If you have already tried the available generics, and they have not been satisfactory and your physician feels a brand name drug may work better, that physician can apply for a waiver of the generic requirement.

Getting Prices For Brand Name And Generic Drugs

CIGNA offers a pricing tool that enables you to compare the costs of drugs. In order to access this tool, you go to www.mycigna.com and log-in. Then, under the heading “My Plans” click on the “View Pharmacy Main Page” tab. That will take you to a screen where you can scroll down to see an area entitled “Prescription Drug Price Quotes” and click on “Go”. You will now be able to enter the name of any drug, and a list with one or more drugs will appear (you can also use the “A-Z” tab, “Class/Category” tab or “Conditions” tab to find your drug). Click on the name of the drug that matches your inquiry. Choose the appropriate dosage and frequency and click on “Select a Pharmacy”. Then click on the box next to any pharmacy for which you wish to check the price. Then click “Compare Prices”. On that page you will see the price of the drug and a comparison with the price to any available generic alternative, as well at the price through the mail order CIGNA Tel-Drug program.

Entering that name will not only provide a price estimate for that drug, but it will bring up any available drug that is a generic or therapeutic alternative to that drug and provide a price estimate for that as well. So you will be able to see your alternatives and estimate the savings that may be available if you use the alternative instead of the brand name drug. The savings available through the Tel-Drug program will also be displayed. You can also call CIGNA at 1-800-244-6224 and get the same information that is available on their web-site.


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NON-DRUG NEWS: Change in Fund Office Live Phone Service Hours

Effective July 1, the Fund Office will provide live phone service from 9:30 AM to 7:00 PM Eastern Time (walk-in hours of 9:30 AM to 5:30 PM remain in place). A study of member call patterns showed that there were very few calls after 7:00 PM and that staffing for live service until 8:00 PM E.T. adversely affected Fund Office phone service during the much busier mid-day hours.