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:
- Walmart (including Sam's Club Pharmacy)
- Albertsons (including Osco Drug)
- Access Health (a group of independent 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 .
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 and generics changing from tier 1 to tier 2 .
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.
Top Most Often Used Drugs that Will No Longer Be Covered**
|Amrix||Androgel 1%||Benicar HCT|
|Proventil HFA||Pulmicort Flexhaler||Qnasl|
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 , 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 , 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 , 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.
** May not apply to all strengths/formulations. Third party brand names are the property of their respective owners.