CBIA Healt Connections 51+ Formulary

A medication formulary is an extensive list of safe and effective brand name and generic prescription drugs. It is a guide for physicians when they prescribe and pharmacists when they dispense medications. Drugs that appear on the formulary have been chosen on the basis of sound medical data, safety and cost. ConnectiCare, Health Net and Oxford Health Plans have determined that a carefully managed formulary process can decrease drug costs while ensuring high-quality medical care.

Does the CBIA Health Connections prescription drug benefit incorporate the use of formularies and generic drugs?

Yes. The prescription benefit under the CBIA Health Connections plan has always been a formulary-based, program. A formulary-based program requires that any medication filled for a member (brand or generic) must be included on the member’s health plan formulary to be covered.

What is the difference between a brand-name drug and a generic?

Brand-name drugs are protected by a patent and manufactured by a specific company. Generic drugs are manufactured according to the same chemical formula of the brand-name drugs whose patents have expired. The Food and Drug Administration (FDA) requires that generic drugs have the same active chemical composition, and have the same potency and be offered in the same form as their brand-name counterparts. Brand-name drugs usually cost more than generic because the manufacturer of the brand-name drug had to adjust the cost of the drug in order to recover research and development expenses.

What happens if a member’s current medication is not covered on the formulary?

Members may perceive the use of a formulary to be a restriction or decrease in benefits, in that some medications they currently use are not covered. Members should be made aware that: (a)medicines excluded from the formulary may be excluded because they may be less effective; (b) may cause more side effects; (c) or may cost more without having any clinical advantage. For each drug that is excluded from the formulary there is an alternative that is at least as effective.

Are doctors and pharmacists aware of which medications are on the formulary?

Yes. Each health plan company communicates its formulary to its network doctors and pharmacies. Members are also encouraged to be proactive and remind their doctor that their health plan company has a formulary so they can prescribe a medication that is covered.

How does a three-tier copay work?

The lowest copay of a three-tier copay applies to generic formulary drugs, the mid-level corresponds to brand name medications on the formulary, and the highest copay applies to nonformulary drugs.

For Health Connections members the three tier copay is as follows:

HMO & POS $10 Plans (CT): $10/$15/$30

$10 Generic Formulary Drugs
$15 Brand Name Formulary Drugs
$30 Nonformulary Drugs

HMO & POS $20 Plans (CT): $10/$20/$40

$10 Generic Formulary Drugs
$20 Brand Name Formulary Drugs
$40 Nonformulary Drugs

HMO & POS $30 Plans (CT): $10/$20/$40

$10 Generic Formulary Drugs
$20 Brand Name Formulary Drugs
$40 Nonformulary Drugs

Oxford USA: $10/$20/$30

$10/$20/$35 copay
$10 Generic Formulary Drugs
$20 Brand Name Formulary Drugs
$35 Nonformulary Drugs

What is step therapy/prior authorization?

Step therapy requires a member to try a “first step” medication, generally a generic drug, before moving to a higher cost drug. A physician may request prior authorization for second or third step medication, if medically necessary. ConnectiCare, Health Net, and Oxford have a prior authorization requirement for certain medications. Use the following links to view the medication lists.

ConnectiCare
medication list

Health Net
medication list

Oxford
medication list

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