SEBAC Prudent Rx


Prudent RX Program Now Included Option for Health Insurance

SEBAC and the Lamont Administration reached a tentative agreement to include the voluntary Prudent RX Program in our health insurance. The tentative agreement is contingent on the Coalition and local tables reaching agreement on new collective bargaining agreements. Adding the RX Program is an improvement to our plan. It will reduce the cost of specialty medication, reduce premium costs by saving the plan money, and is completely voluntary.  Because it saves money for both members and the plan, members will automatically be opted in on the effective date (which is still to be determined) as well as each open enrollment period.  However, any member may opt out if they prefer to keep their current specialty drug coverage.

What is the Prudent RX program?

Prudent RX is a completely voluntary program that allows our insurance plan to apply manufacturer assistance to the cost of specialty medications to reduce health plan costs by the amount of the manufacturer assistance while reducing patient out-of-pocket costs to $0. The program applies only to members who are prescribed specialty drugs and does not apply to any non-specialty drugs they may have.

What is a specialty drug? 

Generally, specialty drugs are high-cost medications used to treat complex or rare medical conditions.  Which drugs are considered “specialty drugs” under an insurance plan can change.

The State Employee Plan defines “specialty drug” as a “drug prescribed by a Physician having one or more of several key characteristics, including: (1) Requirement for frequent dosing adjustments and intensive clinical monitoring; (2) Need for intensive patient training and compliance for effective treatment; (3) Limited or exclusive product distribution.”

Is the Prudent RX Program Voluntary?

Yes! The Prudent RX Program is completely voluntary. Every member will have the choice to opt out and face no penalty for doing so.

What are the benefits of participating in the Prudent RX Program if you take a specialty drug?

If you participate, you no longer will have copays for specialty medications, which are currently between $6-$40 – almost always the latter. This means members with just one monthly specialty medication can save up to $480 a year, and some members with multiple specialty medications can save up to $2,400 a year. There will also be a small cash payment for those that participate and complete the requirements. In addition, the Prudent RX program is projected to save our health insurance plan millions of dollars a year, which will help lower premium costs for everyone on the plan.

What is required of me if I participate?

If you participate, you will be required to complete an application for each specialty medication. The application takes about five minutes to complete, and someone from the Plan will be available to assist you in filling out the application.

What if I fail to meet the requirements of participation? Is there a penalty?

You will be ineligible to participate in the Prudent RX program in future plan years, but there are no penalties for failing to meet the requirements.   Your specialty medications continue at zero co-pay for the remainder of the plan year.

If I don’t take any specialty medications, how does this affect me?

If you do not take any specialty medications, this will not affect you except to the extent that the program lowers premium shares for all plan participants. You will not be required to complete an application.

Does the Prudent RX program apply to retirees?

The Prudent RX program will apply to pre-Medicare retirees only.