New Specialty Medication Split Fill Program
Specialty medications are often expensive. Medications may also include side effects that prevent patients from taking the medication or require a change to the dosage. To help reduce waste and your out-of-pocket costs, the UC Blue & Gold HMO plan is implementing a “split fill” program. For high-cost, orally administered anti-cancer drugs with numerous adverse effects, members can obtain an initial two-week trial supply to determine if the patient can tolerate the high-cost therapy before obtaining and paying for a full prescription supply.
Beginning in January 2022, members will receive up to a 14-day trial supply, with no copayment, of any newly prescribed specialty medication to allow time to test tolerance to the medication and discuss any side effects with their doctor before filling the entire prescribed amount.
Change to Generic Substitutions
In 2021, if it is medically necessary for you to take a brand-name medication when a generic equivalent is available, you pay either $25 (brand formulary) or $40 (non-formulary) for up to a 30-day supply. If it is not medically necessary, you pay either $25 (brand formulary) or $40 (non-formulary) for up to a 30-day supply, plus the cost difference between the brand-name medication and the generic equivalent.
Beginning in January 2022, if it is medically necessary for you to take a brand-name medication when a generic equivalent is available, you will pay $40 (for up to a 30-day supply) or $80 (for up to a 90-day supply).
Your doctor will need to provide documentation to Health Net (through the prescription drug prior authorization process) explaining why you are unable to take a generic equivalent. Without prior authorization from Health Net, there is no coverage for brand-name drugs when a generic equivalent is available. You will be responsible for 100% of the cost, and it will not count toward your annual out-of-pocket maximum.