[UCRDBR] Health Net – UC Blue & Gold HMO MAC Prescription Policy Member Communication

[Departmental Benefits Representatives]

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November 19, 2021
To:
Department Benefits Representatives (DBRs)
From:
HR Benefits Office on behalf of the UC Office of the President
Re:
Health Net – UC Blue & Gold HMO MAC Prescription Policy Member Communication
UCOP announced that the Maximum Allowable Charges (MAC) policy on generic drug substitution for the UC Blue & HMO Health Net plan is changing to a standard structure effective January 1, 2022. An Important Message from Health Net of California, Inc. and Health Net Life Insurance Company (Health Net) will be sent to affected members by Friday, November 19, 2021.

UC currently has a custom MAC policy that covers brand name drugs when a generic equivalent is available, regardless of medical necessity. In the current structure:

·       If the brand drug is medically necessary, the member pays either a Tier 2 or Tier 3 copay.

·       If the brand drug is not medically necessary, the member pays the copay of the brand drug plus the difference in cost between the brand and generic drug.

Effective January 1, 2022:

·       If the brand drug is medically necessary, the member pays the Tier 3 copay. This may result in a $15 monthly increase for some members who would have paid the Tier 2 copay in the current structure.

·       If the brand drug is not medically necessary, the member has no coverage for the brand drug.

For Brand name drugs where there is no generic equivalent available, the applicable copayment (Tier 2 or Tier 3) will apply.

Prescription medical necessity is determined by Health Net’s prescription drug prior authorization process.

For questions about this new policy, employees should contact Health Net directly using the number on the back of the Health Net member ID card or reach out to the UCR Health Care Facilitator at benefits at ucr.edu<mailto:benefits at ucr.edu>.

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