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Mandatory Generic Drugs

The OLDC-OCA Insurance Fund only covers the cost of the generic drug (if a generic is available). If you or your Physician request the brand name drug, you would be responsible for the price difference between the generic and the brand name drug. In addition to the cost difference, you are still responsible for the brand name Copayment.

A generic equivalent is a copy of a brand-name medication that is no longer protected by a patent. When a new drug comes to market for the first time, the drug company that manufactures it has a patent to be the sole manufacturer. Once the patent has expired, other manufacturers can produce the drug as a generic. A generic drug is identical to a brand name drug in that it is required to have the same active ingredient(s), strength, dosage, way it works, way it is taken, and the way it should be used. When a generic drug product is approved, it has met rigorous standards established by the Food and Drug Administration (FDA). There is little difference between a brand-name drug and its generic equivalent. The generic may differ from the brand-name drug in color, shape, size, or taste, but these things don’t affect the way the drug works, and they are looked at by FDA. The big difference is that generics usually cost less than the brand; therefore, using generic medications can be a significant source of savings for you and the Fund. 

You are encouraged to work with your doctor to use generics, when right for you. Your doctor or pharmacist can assist you in substituting generic medications when appropriate. If you or your doctor feel the generic equivalent drug is not clinically appropriate (e.g., it will be or has been ineffective or would have adverse effects), you are entitled to submit an Appeal of the price difference between the generic and the brand name drug. To find out how to appeal, please contact Anthem-CarelonRx at 855-878-0128.

There are often many drugs (both generic and brand name) that can be used to treat a condition or symptom. Health plans choose drugs to be on their preferred drug list because they are as safe and effective as the alternatives but cost less. A team of pharmacists and Physicians review the preferred list and make changes as necessary and as new drugs come to market.

Medication Type Retail (30-Day Supply) Copayment* Mail Order (90-Day Supply) Copayment*
Tier 1 (Generic)
Tier 2
Tier 3

*Copayments are the cap for or limit to which members will pay for a particular drug. For example, if you get a 30-day supply of a generic medication, you will never pay more than $10 for that fill. If the medication is less than $10, you will just pay the smaller amount.

Step Therapy: Certain medications may qualify for a step therapy program. Step therapy requires one Drug, Drug regimen, or treatment be used prior to use of another Drug, Drug regimen, or treatment for safety and/or cost-effectiveness when clinically similar results may be anticipated, Step therapy helps you and the Fund control the rising cost of drugs. Your doctor can ask for an exemption from the step therapy protocol for you by contacting Anthem online or by calling the phone number on your ID card If the request is approved, you will only pay the appropriate Copayment for the drug. If it is not approved, you may need to pay up to the full price of the drug. You can always find the most current information about drugs that have a step therapy requirement when you log in at anthem.com or call Pharmacy Member Services. Drugs will be added to or removed from the step therapy program when deemed appropriate by Anthem – CarelonRx.

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