2018 Prescription Drug Changes for 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 provided through your employer, you may see some 2018 pharmacy benefit changes. Knowing what’s changing for 2018 may help you when choosing your 2018 health care plan.

Starting January 1, 2018, these changes in your 2018 pharmacy benefit program and drug lists will be made:

Drug List Changes

Prescription drug lists have many levels of coverage, called payment level tiers. Your pharmacy benefit for 2018 may have up to six payment level tiers.

Drugs that move to a higher payment level tier may still be covered. However, you may have to pay more out-of-pocket based on your benefits. Talk with your doctor if you have any questions about your prescription.

Here are your 2018 drug tier changes:

Prescription Drug Payment Level Tiers

The lower the drug tier, the lower your out-of-pocket cost may be.

*Not all plans have 6 tiers.

Drugs No Longer Covered

Some drugs will no longer be covered in 2018. Make sure to talk with your doctor about your options for covered generic or brand alternative drugs. See below for the most often used drugs that will no longer be covered, a list of covered alternatives for these drugs and a full list of drugs that will no longer be covered.

Also, drugs that aren't U.S. Food and Drug Administration (FDA) approved are not covered.

Commonly Used Drugs No Longer Covered*

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

Coverage for new drugs added to your plan will begin when your 2018 plan renews or starts.

Sample of Newly Covered Drugs*

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

Full list of drugs added to your pharmacy benefit

View your 2018 drug list (for coverage that renews or starts on or after January 1, 2018):

* Applies for Blue Choice Preferred Silver PPO 102 only

New drugs are being added to the utilization management programs when your coverage renews or starts in 2018. Select the program name to view its list:

Program

If you use a drug manufacturer's coupon or copay card to pay for a covered prescription drug, this amount will not apply to your plan deductible or out-of-pocket maximum (unless it is a permitted third-party cost sharing payment).

Using In-Network Pharmacies

Your pharmacy network is made up of a nationwide network of contracting pharmacies. If you use an in-network pharmacy, your out-of-pocket costs may be lower than if you use a pharmacy not in the network.

If you use an in-network pharmacy in 2018:

  • Copays/coinsurance amounts will apply to the in-network out of pocket spending amounts
  • Pharmacy costs will apply to the in-network deductible (if your plan has one)
  • Pharmacy costs will be lower

If you use an out-of-network pharmacy in 2018:

  • Copays/coinsurance amounts will apply to the out-of-network and out-of-pocket spending amounts
  • Pharmacy costs will apply to the out-of-network deductible (if your plan has one)
  • Any additional charges you may pay will not apply to any of the out-of-pocket spending amounts (based on your plan)
  • Pharmacy costs may be higher

Your pharmacy benefits may also have a Preferred Pharmacy Network (PPN). You’ll see the highest out-of-pocket savings when going to a PPN location. Find an in-network pharmacy.

In Network

Non-Preferred Pharmacies

Out of Network

More Pharmacy Benefit Information

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 standards before prescription drug benefit coverage may be approved. Remember, pharmacy and treatment decisions are always between you and your doctor. Only you and your doctor can decide which medicine is right for you.

Answers for Your Questions

If you are a BCBSIL member, you have many ways to learn more about your pharmacy benefits:

Log in to your Blue Access for MembersSM (BAMSM) account

Login to BAM

See your plan materials for pharmacy and prescription plan information

See Plan Information

Call the number on the back of your member ID card

Footnotes

  1. Members with a health plan provided through their employer will see these changes on their 2018 plan renewal date, unless otherwise listed.

  2. This change will not be made for Blue Choice Preferred Silver PPO 102.

  3. Preferred Pharmacy Network pricing isn’t available for 100% cost-sharing plans and IL HMO plans. These 100% cost-sharing plans don’t have a tiered structure for member out-of-pocket copay/coinsurance for prescription drugs.

  4. You can also fill up to a 90-day supply at a retail pharmacy in the Preferred Pharmacy Network. Members with an IL HMO plan can use select pharmacies in their network to get up to a 90-day supply of a covered prescription.