Learn about the differences between brand name and prescription drugs.
What is the difference between brand-name drugs and generic drugs?
When a drug company develops a new medication they apply for a patent. This patent protects the drug from being copied by other drug companies for a certain period of time. These drugs are brand name drugs. Once the patent period expires, other manufacturers can produce the same drug as long as they follow strict guidelines established by the Food and Drug Administration's (FDA) guidelines. These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose patents have expired. They are made with the same active ingredients of the brand name drug, but they may have a different color, shape or filler material. The cost of a generic drug is typically less than a brand name drug. All generic medications are approved by the FDA before they are released on the market. Some examples of generic drugs and their brand name equivalent include furosemide and Lasix®, ranitidine and Zantac®, and cephalexin and Keflex®.
What is the difference between a generic equivalent and a generic alternative?
A generic equivalent is a medication that contains the same active ingredient and works the same way as the original brand name drug. A generic alternative is a generic medication that may not have the same active ingredient, but works in the same way as another drug. An example of a generic alternative is ranitidine. It is the generic equivalent of Zantac®, but it works in the same way to relieve stomach acid as Axid® and Pepcid®.
Zantac, Axid, and Pepcid are the same “class” of medicine but contain different active ingredients. So, the generic form of Zantac, “ranitidine,” is a lower cost alternative in the same class of medicine as Axid and Pepcid.
How is the tier level status determined for medications?
The Prescription Drug List (PDL) is a list of prescription medications that have been reviewed and recommended by the Blue KC Medical and Pharmacy Management Committee. The list has a combination of brand name and generic medications. Each of these medications has been reviewed for its safety, effectiveness, clinical outcomes, and cost. Physicians and pharmacists on the committee look at drug utilization issues, the number of adverse events, and any proven advantages over other drugs on the PDL. The most efficient and cost effective drugs are on Tier 1 of the PDL. All other drugs are designated Tier 2 or Tier 3 status. If your health insurance plan is offered through your employer, download the Blue KC Prescription Drug List to see a list of all covered drugs by tier. Otherwise, download a list of the most commonly prescribed medications.
What is a maintenance drug?
A maintenance drug is a medication used to treat a chronic condition like diabetes or high blood pressure. The FDA must approve maintenance drugs as safe for long-term use. Blue KC uses a national drug information database called First DataBank to determine which medications are included on the maintenance drug list. If your prescription is a maintenance drug, you can have it filled for several months instead of just one prescription at a time.
Do I need to show my member ID card at the pharmacy?
Yes, show your member ID card to your pharmacist whenever you have a prescription filled. Your prescription claim is electronically transmitted to Blue KC when you fill your prescription. Please make sure the pharmacy has your most current health insurance information and correct birth date so there won’t be any delays or claim denials when we process your claim.
What do I do if I need to refill my prescription early (i.e., leaving on vacation, the doctor increased my dosage)?
To have a prescription refilled early, have your pharmacist call the Pharmacy Customer Service unit at 816-395-2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.
What if I am out of town and need to have a prescription filled?
Blue KC contracts with most major pharmacy chains and has a network of over 44,000 pharmacies nationwide. If the pharmacy you are using has difficulty in processing your prescription claim, have them contact the Pharmacy Customer Service unit for assistance at 816-395-2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.
Why does Blue KC require prior authorization for some drugs before they are covered?
Blue KC may require prior authorization for some drugs or a class. Medications on the prior authorization list may have safety concerns or have FDA approval, only for a certain use. Some of the prior authorization medications may also have a lower-cost alternative that should be considered first or the drug may not be as effective as something else in the same drug class. Some medications are also on the prior authorization list because they have the potential to be misused. Your provider and Blue KC will work together to get prior authorization and approval for your prescription when needed.
What if I have questions about my prescription drug coverage?
For more information on your prescription drug coverage, call the Pharmacy Customer Service unit at 816-395-2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.