Prescription Drug Benefit Changes for 2017 Individual or Employer-offered "Metallic" Plans

If you have a Blue Cross and Blue Shield of Illinois (BCBSIL) "metallic" health plan now, either purchased on your own or offered through your employer, some pharmacy network, formulary and other pharmacy benefit program changes will be made. This information may be helpful when you are choosing a health plan during Open Enrollment for 2017.

Starting January 1, 2017, these changes will be made:*

For PPO Members Only: Preferred Pharmacy Network Changes

Changes have been made to pharmacies included in the Preferred Pharmacy Network. When you fill a prescription for up to a 30-day supply of a covered prescription drug from a retail pharmacy that contracts to participate in the Preferred Pharmacy Network, you may pay the lowest copay/coinsurance amount. If you fill a prescription at a non-preferred, in-network pharmacy, you may pay a higher copay/coinsurance amount.

You may also fill a prescription for up to a 90-day supply of a covered prescription drug at a retail pharmacy that participates in the preferred pharmacy network.

The pharmacies participating in the Preferred Pharmacy Network on January 1, 2017 are:

  • Walgreens
  • Walmart (including Sam's Club Pharmacy)
  • Albertsons (including Osco Drug)
  • Access Health (a group of independent pharmacies)

See the complete list of preferred pharmacies PDF Document. You can also view this list on myprime.com  by selecting the "Health Insurance Marketplace Network" and filtering for preferred pharmacies.

Pharmacy Network Changes

On January 1, 2017, regardless of renewal date, CVS Pharmacies and CVS Pharmacies in a Target store are no longer in your pharmacy network for PPO members. If you continue to fill your prescriptions at a CVS pharmacy after January 1, 2017, you will pay more. To find an in-network pharmacy, visit myprime.com .

For HMO Members Only: IL HMO Specialty Pharmacy Network

On January 1, 2017, regardless of renewal date, benefits for covered specialty drugs for HMO members will only be available from pharmacies that are contracted to participate in the IL HMO Specialty Pharmacy Network. Specialty drugs are those listed as Tier 5 on the Drug List. View the Specialty Pharmacy Network PDF Document.

Drug List Changes

Some drugs are changing from a preferred brand (Tier 3) to a non-preferred brand (Tier 4) payment level tier. Also, some generic drugs will move from a preferred generic (Tier 1) to a non-preferred generic (Tier 2) tier. These drugs may still be covered. But you may have to pay a higher copay or coinsurance amount, based on your benefit plan.

If you are taking, or are prescribed, one of the drugs affected by these changes, ask your doctor if a generic drug or lower cost preferred brand alternative drug is right for you. Depending on your prescription drug benefit, these drugs may cost you less. Please note that treatment decisions are always between you and your doctor.

You can view the full list of brand drugs that are changing from tier 3 to tier 4 PDF Document and generics changing from tier 1 to tier 2 PDF Document.

Drugs No Longer Covered

Select products will no longer be eligible for coverage under the prescription drug benefit. A covered generic or brand alternative drug may be available. As a reminder, medicines that have not received U.S. Food and Drug Administration (FDA) approval are not covered for safety concerns. If you are taking, or are prescribed, one of these drugs that will no longer be covered, ask your doctor about therapeutic alternatives.

Below is a table showing the top most often used drugs that will no longer be covered. You can view a list of their covered alternatives PDF Document and the full list of drugs that will no longer be covered PDF Document.

Top Most Often Used Drugs that Will No Longer Be Covered**

Abilify Absorica Amitiza
Amrix Androgel 1% Benicar HCT
Dymista Leuprolide Acetate Nucyntal
Onexton Pazeo Pennsaid
Proventil HFA Pulmicort Flexhaler Qnasl
Tudorza Pressair Veramyst Vytorin
Xopenex HFA Zovirax  

Utilization Management Programs Added

New drugs are being added to the prior authorization and step therapy programs under your prescription drug benefit plan. Dispensing limits are also being added to select drugs.

If your drug is part of the prior authorization program PDF Document, you will need to have your doctor request pre-approval, or prior authorization, from BCBSIL before you can get benefits for select drugs. If your drug is part of the step therapy program PDF Document, you will need to have a prescription history for a preferred drug before your benefit plan will cover some other drug. If your drug has a dispensing limit PDF Document, you will get coverage only for what the dispensing limit allows.

If you are taking, or are prescribed, a drug that is part of these new programs, or think these new programs might affect you, please talk to your doctor now.

For Individual Plan Members Only: Coupons

If you paid for a covered specialty prescription drug at Prime Specialty Pharmacy by using a drug manufacturer's coupon or copay card, this amount will not apply to your plan deductible or out-of-pocket maximum, unless it is a permitted third-party cost sharing payment.

Remember: Treatment decisions are always between you and your doctor. Only you and your doctor can decide which medicine is right for you. Talk with your doctor, or pharmacist, about any questions or concerns you have about medicines you are prescribed. Coverage is based on the limitations and exclusions of your benefit plan. For some medicines, members must meet certain criteria before prescription drug benefit coverage may be approved. See your plan materials for details.

If you have any questions, call the number on the back of your ID card.

* Members with a health plan offered through their employer will see these changes on their 2017 plan renewal date, unless otherwise listed.

** May not apply to all strengths/formulations. Third party brand names are the property of their respective owners.