STATE HEALTH BENEFITS
EMPLOYEE PRESCRIPTION DRUG PLAN
Third Tier Copayment Exception
FOR STATE ACTIVE GROUP MEMBERS
A member of the Employee Prescription
Drug Plan may obtain a third tier brand name prescription
drug that has a generic equivalent for the
lower copayment of a brand name prescription drug without
a generic equivalent if it can be established that the patient
either has an intolerance to the drug's generic equivalent
or there is a therapeutic failure of the
If your doctor advises that you must
use a brand name prescription drug due to intolerance and/or
therapeutic failure of the drug's generic equivalent, the
doctor needs to provide sufficent documentation to Express Scripts
in order for you to receive the drug
at the lower brand name copayment.
Your physician should complete the U.S
Food and Drug Administration's
MedWatch Form or submit similar medical record
information that documents the finding, and forward it to
Medco for consideration.
During Express Scripts/Medco's review process,
you will still be able to obtain your prescription by paying
the higher copayment. If Express Scripts/Medco approves your request, you
will be reimbursed the difference in the copayment amount.
If your request is denied, you can appeal that decision
through Express Scripts/Medco's appeal procedure.