Generic or brand name drugs -- What’s in a name?

There’s confusion when it comes to the differences between brand name and generic drugs, and the false perception is that generic brands aren’t as good.

The U. S. Food and Drug Administration (USDA) requires that generic drugs have the same chemical composition, potency and effect on the body as their brand-name counterparts. Only the inactive ingredients that determine the drug’s shape, color and size are allowed to differ from those of the brand-name version.

According to the USDA Office of Generic Drugs, approximately 42 percent of brand-name drugs currently have generic equivalents. Because those generics can cost from 40 to 60 percent less than the brand-name drugs, the savings is passed along to the beneficiary as a lower co-payment and to the U.S. taxpayer in the lower purchase price for the generics.

The Department of Defense (DoD) policy requiring generic drugs for filling TRICARE prescriptions saves TRICARE beneficiaries money, both as consumers and taxpayers.

When the prescription is filled at a TRICARE network pharmacy, the co-payment for up to a 30-day supply of a generic drug is only $3. For a medically necessary brand-name drug, the co-payment is $9 for up to a 30-day supply.

If prescriptions are refilled through the TRICARE Mail Order Pharmacy (TMOP), the same $3 and $9 co-payments can be paid for up to a 90-day supply of generic or medically necessary brand-name medications.

As always, TRICARE beneficiaries may fill their prescriptions at a military treatment facility pharmacy at no charge if the requested medications are available.

TRICARE’s three-tiered drug policy requires that generic equivalents (Tier One) be automatically substituted for brand-name medications (Tier Two). Exceptions to this policy are made only if no generic equivalent is available or if the prescribing physician documents a medical necessity for the brand-name medication.

If a beneficiary insists on having a prescription filled with a brand-name drug that is not considered medically necessary, and a generic counterpart for that drug is available, he or she will be responsible for paying the entire cost of the prescription out of pocket.

In 2004 the TRICARE Management Activity established a Uniform Formulary rule which created a new third-tier cost share of $22 per prescription—in both mail order and retail pharmacy services—for medications that are not included in the TRICARE Formulary. A recommendation to remove a drug from the formulary is based on the drug's relative clinical and cost effectiveness compared with other drugs in the same therapeutic class.

However, if medical necessity is established for a non-formulary drug, patients may qualify for the $9 copayment for up to a 30-day supply at a TRICARE network pharmacy or a 90-day supply in the TMOP program. Note that MTFs are prohibited, under the Code of Federal Regulations, from carrying non-formulary medications.

Find more information about TRICARE pharmacy benefits at www.tricare.mil/pharmacy or www.triwest.com. To learn more about the TRICARE Mail Order Pharmacy contact Express Scripts at 1-866-DOD-TMOP (1-866-363-8667) or visit www.express-scripts.com.