2-150 Insured Groups, 151+BluePrintSM Groups Affected
To encourage safe, cost-effective medication use and help control pharmacy trends, Blue Cross and Blue Shield of Illinois (BCBSIL) is changing the prescription drug benefit program effective upon renewal on or after January 1, 2009, for 2-150 insured groups and 151+ BluePrint groups.
Prior Authorization/Step Therapy Program to Be Added
The prior authorization/step therapy program will be added to all prescription drug benefit plans for the affected groups.
Prior Authorization (PA): Designed to promote patient safety and use of the drug as intended by the manufacturer and the U.S. Food and Drug Administration, this program is intended to help reduce the potential for medication misuse and abuse, and encourage cost-effective medication use. The PA program requires the member's physician to obtain authorization from BCBSIL before the member can receive coverage for certain medications and drug categories. In the event that prior authorization is not obtained, the member will then be responsible for the first $1,000, or 50 percent of the Eligible Charge, whichever is less.
The following drug categories will be included in the PA program.
- Anabolic steroids
- Growth hormones
- Hepatitis C medications
- Oral fentanyl
Step Therapy (ST): Step therapy, a type of prior authorization, is designed to encourage the initial use of alternative medications generally recognized as safe and effective, which are also lower-cost. Under this program, in order to receive coverage the member may need to first try a proven, cost-effective medication before progressing to a more costly treatment, if necessary. After the member has a prescription history for a lower-cost alternative medication, coverage will automatically be provided for a more costly medication included in the program.
Step therapy is automatic for new groups with effective dates on or after January 1, 2009. For renewing groups (groups with prescription drug benefits through BCBSIL prior to January 1, 2009), all initial claims submitted for a drug included in the ST program after the group's renewal date will be processed under the program. Continued coverage will be provided for members who have a claims history for a drug included in this program prior to the PA/ST program becoming part of the prescription drug benefit program.
The following drug categories will be included in the ST program.
- Hypertension (ACE inhibitors/ARBs)
- Insomnia
- Rheumatoid arthritis/psoriasis
Diabetic Supplies to Be Assigned Formulary Status
BCBSIL is changing how coverage is determined for diabetic supplies for all formulary-based prescription drug benefit plans for these groups. For new groups and upon renewal on or after January 1, 2009, for existing groups, diabetic supplies will be assigned a formulary status and benefits will be paid based on that status.
Communicating Rx Changes
Employer groups have been notified of these changes in the fall issue of the Benefits Management Briefing newsletter. Targeted mailings will be sent to members affected by the addition of the prior authorization program and coverage for diabetic supplies.
If you have questions about these changes, contact your general agent or account executive. |
