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URx: Rethinking our Rx program:
A New Strategic Approach
Clinical Monographs From
PTAC (Pharmacy & Therapeutics Advisory Committee)
Independent Committee consisting of the following:
3 Active Practice Physicians
3 Active Practice Pharmacists
3 Consumers - Plan Members / Retirees / Union Reps
Drug is tiered A,B,C,D, or F
 Efficacy evaluated first
The Higher the Value,
 Cost evaluated second
The Higher the Drug is tiered.
 Efficacy + Cost = Drug Value
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URx Benefit Design
URx Medication Classification
(Based on medical evidence of impact to health and overall net cost)
Excellent level of value based on best medical evidence, best opportunity for
improved health outcomes via disease management, and best overall net cost. This
tier includes both generic and brand name medications.
High level of value based on medical evidence of outcomes and lower overall net
cost savings. Includes both generic and brand medications compared to higher cost
brand name counterparts.
Good level of value based on fair medical evidence grading, but displaying higher
overall net cost relative to generic counterparts and less expensive brand name drug
or clinical alternatives.
Lower level of value based on evidence of outcomes relative to other clinical
alternatives. Generally have much higher overall net costs. [Coinsurance is calculated
on the discounted cost of the medication. Discounts have been negotiated for most
medications purchased through URx.]
These medications have the lowest level of value (based on clinical evidence) or the
highest overall net cost in relation to generic or other brand alternatives.
[Coinsurance is calculated on the discounted cost of the medication.. Discounts have
been negotiated for most drugs purchased through URx.]
Medication
Class
Deductible
Retail Rx
(30-day supply)
Mail Rx
(90-day supply)
Tier A
$0*
$0 Copayment
$0 Copayment
Tier B
$0*
$15 Copayment
$30 Copayment
Tier C
$0*
$40 Copayment
$80 Copayment
Tier D
$0*
50%**
Coinsurance
(You pay half of
the discounted price)
Tier F
$0*
50%**
Coinsurance
(You pay half of
the discounted
price)
100%**
100%**
Coinsurance
Coinsurance
(You pay 100% of
(You pay 100% of the
the discounted
discounted price)
price)
Specialty Pharmacy Program. Specialty drugs are defined as high cost prescription
medications that may require special handling and/or administration to treat
$50 copay / $200
chronic, complex conditions. These medications may be taken orally but often are
Tier S
$0*
Not Covered
copay
injectables with a complex manufacturing process or may have a limited distribution
status. This specialty program includes medications to treat Hemophilia, Arthritis,etc.
*Members on a High Deductible Health Plan (HDHP) will pay 100% of the cost of their medications until their medical plan deductible is met. See
reverse for more information.
**Co-insurance payments for D & F medications do not accumulate to the out-of-pocket maximum.
—For members on RM or CM plans, URx plan has an out-of-pocket prescription maximum of $1,650 ($3,300 family).
—For members on HDHPs, URx uses the plan’s medical out-of-pocket maximum.
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How Will URx Work For Me??? THE URx 4 STEP
STEP 1
Review Your Medications – Know what they are………..
 Complete Name
 Dosage – i.e. 10mg, 20mg. etc
 Frequency – i.e. Once daily, Twice daily, etc.
STEP 2
Find out what tier your drugs received under the URx
drug list.
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How Will URx Work For Me??? THE URx 4 STEP
STEP 3
 If they are D or F, you can find out about potential alternatives in
classes A through C to discuss with your doctor. Call Ask-aPharmacist at 1-888-5-ASK-URX (527-5879) for assistance if
needed.
 We will be mailing letters to members who have D and F drugs throughout
the year to assist you with learning about your drugs and potential
alternative drugs.
STEP 4
 If there are documented medical reasons why you cannot take one of the
alternative drugs with a higher grade, URx Ask A Pharmacist staff can work
with you to see if you are eligible to receive a better benefit for a lower grade
drug. Have your PROVIDER complete and submit a Plan Exception Request
form (available on-line, or call 1-888-527-5879).
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How do I find out my drug tier?
 There are several ways to look up the tier of your drugs
and potential alternatives:
•
Call general information at URx: 1-888-648-6764
•
On the internet go to www.urxpharmacy.org
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For all MUST members your
member ID # is a 9 digit
number starting with 87 and
EXCLUDES the -01 behind
your ID number. For example,
use 871234567 to register. DO
NOT include 871234567-01.
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Where do I go to fill my prescriptions ?
You can still use all of the same retail pharmacies.
 In addition to Ridgeway Mail Order, URx also utilizes
Costco Pharmacy for mail-order prescriptions.
Diplomat Specialty Pharmacy is the URx provider for
Specialty Drug Services. If you are currently in the
specialty drug program, Diplomat will be in contact with
you prior to July 1, 2013.
S-$50 & S-$200 Specialty Medications
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Questions?
General information on
URx available at:
1- 888-648-6764n
the internet go
twww.urxpharmacy.org
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