Generic Incentive Provision
For all prescription drug purchases, whether at a retail drug store or through mail-order, members will be responsible for paying the difference between the price of a generic prescription drug and a brand-name prescription drug, plus coinsurance, if purchasing a brand-name drug when a generic is available. (The difference in cost between the brand-name drug and the generic drug does not apply toward your annual out-of-pocket maximum.) Here's an example of how the "Generic Incentive Provision" works:
Example of a brand-name purchase versus a generic purchase:
Al purchases a 30-day supply of Mevacor, a brand-name prescription drug, at the local pharmacy. He chooses not to use the generic alternative, Lovastatin.
Drug Name and Price
Lovastatin ($24.04)
Mevacor ($79.10)
(15% of $24.04)
(25% of $79.10)
Price difference between brand-name and generic
Not applicable
($79.10 - $24.04)
Member's Total Cost
($19.78 + $55.06)
Extra cost for member to purchase brand-name drug
($74.84 - $3.61)
If Al had elected to use the generic alternative, Lovastatin, his coinsurance would have been 15% of the $24.04 price tag of the generic drug, or $3.61. However, because he chooses to purchase the brand-name drug (Mevacor) when a generic is available, his coinsurance will be 25% of the higher price for the brand-name drug, or $19.78. In addition to this coinsurance amount, he must pay the full difference in price between the brand name and generic ($79.10 - $24.04 = $55.06). In total, Al must pay $74.84 for the brand-name prescription (coinsurance amount of $19.78 plus the brand-generic price difference of $55.06). By purchasing the generic version, Al could have saved $71.23. (Please note that prices shown in this example are for purposes of illustration. Actual prices may vary.)
Certain brand-name drugs will not be subject to the "pay the difference" penalty. These brand-name drugs are on Express Scripts' Narrow Therapeutic List which changes from time to time. In addition, if no generic version exists for a brand-name drug, the penalty will not apply. Only the 25% brand coinsurance will apply to the purchase of these brand-name prescription drugs. Your participating pharmacy has Express Scripts' Narrow Therapeutic List and will charge you the correct coinsurance amount.