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Drug costs for the North Carolina Teachers' and State Employees' Comprehensive
Major Medical Plan have been increasing at an alarming rate. To control these
costs, the General Assembly of North Carolina recently approved changes in the
law related to the pharmacy benefit for State of North Carolina employees.
As a result of that legislation, the State Health Plan executive administrator
has contracted with Advance PCS to act as pharmacy benefit manager for the
program. Employees covered by the State Health Plan should have received
letters at their home addresses explaining the new program.
The new pharmacy benefit manager (PBM) began oversight of the drug program on
Dec. 1. Some important provisions of this plan include:
* Covered prescription drugs are all drugs that are FDA approved, with the
exception of those for erectile dysfunction, as well as antiwrinkle and hair
growth medications. Drugs for weight loss will require prior authorization.
Insulin is treated as a prescription drug.
* Medical supplies are not covered under the prescription drug benefit. They
are subject to the annual deductible and copayments required by the medical
plan. Covered medical supplies include diabetic syringes and needles, test
strips, colostomy supplies, oxygen and other similar supplies. Claims for
covered medical supplies can continue to be filed to the medical claims
processing contractor, Blue Cross Blue Shield of North Carolina.
* Employees will receive a new identification card prior to Jan. 1, 2001. The
new card will be used as the medical and prescription drug card. Under the new
program, there will be a network of participating pharmacies. A partial listing
was included with the letter mailed to employees. The network includes more
than 53,000 pharmacies. For information about pharmacies in the area, contact
Advance Paradigm, Inc. at 800-929-2524. If using a pharmacy that is not
participating with Advance PCS, payment for the prescription at the time of
purchase and submission of a claim for reimbursement will be required. Any
amount above the plan's payment and copayment will be billed to the employee.
* Employees will receive a list of preferred drugs with the mailing including
a new identification card. The employee's physician will also receive a list of
preferred drugs. All covered FDA approved drugs will be available, but drugs
not on the preferred list will require a $25 copayment for each 34-day supply.
All other copayments will remain the same - $10 for generics; $15 for preferred
brand without generic available; and $20 for preferred brand with a generic
available.
* A mail order option is also available under Advance PCS. A form and
instructions were included in the recent mailing. Up to a 102-day supply may be
requested by paying appropriate three copayments, one for each 34 days.
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