STATE HEALTH BENEFITS PROGRAM
EMPLOYEE PRESCRIPTION DRUG PLAN

Third Tier Copayment Exception
FOR STATE ACTIVE GROUP MEMBERS

A member of the Employee Prescription Drug Plan may obtain a third tier brand name prescription drug that has a generic equivalent for the lower copayment of a brand name prescription drug without a generic equivalent if it can be established that the patient either has an intolerance to the drug's generic equivalent or there is a therapeutic failure of the generic equivalent.

If your doctor advises that you must use a brand name prescription drug due to intolerance and/or therapeutic failure of the drug's generic equivalent, the doctor needs to provide sufficent documentation to Express Scripts/Medco in order for you to receive the drug at the lower brand name copayment.

Your physician should complete the U.S Food and Drug Administration's MedWatch Form or submit similar medical record information that documents the finding, and forward it to Medco for consideration.

During Express Scripts/Medco's review process, you will still be able to obtain your prescription by paying the higher copayment. If Express Scripts/Medco approves your request, you will be reimbursed the difference in the copayment amount. If your request is denied, you can appeal that decision through Express Scripts/Medco's appeal procedure.