Reminder: Pharmacy Program Benefit Changes, Effective Jan. 1, 2017

Posted April 27, 2017

Blue Cross and Blue Shield of Illinois (BCBSIL) implemented pharmacy benefit changes on Jan. 1, 2017, for some members with prescription drug benefits administered through Prime Therapeutics.* 

Based on claims data, letters are being sent from BCBSIL to alert members who may be affected by one, or more, of the 2017 pharmacy benefit changes. A summary of the changes, as outlined in the member letters, is included below for your reference. 

Drug List Changes and Medication Coverage Revisions/Exclusions – Some members’ plans may now be based on a new drug list:

  1. New Performance Drug List and Performance Select Drug Lists – Some members may have one of these new drug lists, which are closed drug lists, meaning they will list covered medications only. As a result, some medications will move to a higher copay/coinsurance payment tier and select drugs/drug classes may be excluded from coverage. Additionally, if your patient had a prior authorization approval for a drug that is now excluded from coverage, you can submit a drug list coverage exception request to BCBSIL. Based on this change, your patient may ask you about therapeutic alternatives.
  2. Enhanced Drug List (formerly known as Generics Plus Drug List) – Some members may move to this drug list, and as a result, select medications may move to a higher copay/coinsurance payment tier. Based on this change, your patient may ask you about generics or lower cost alternatives.
  3. Some members may also be affected by annual or quarterly drug list changes, such as drugs moving to a higher payment tier or excluded from coverage. Based on this change, your patient may ask you about therapeutic or lower cost alternatives.
  4. The Standard Drug List is now known as the Basic Drug List.
  5. As a reminder, medications that have not received U.S. Food and Drug Administration (FDA) approval are not covered under the BCBSIL pharmacy benefit. 

Utilization Management Program Changes – Some members’ plans may now be subject to new prior authorization and step therapy programs and/or dispensing limits. If your patient is taking any of the selected medications included in these programs, your patient may need to meet certain criteria, such as an approval of a prior authorization request, for coverage consideration. Additionally, these programs may correlate to your patient’s drug list. (For example, if a particular drug is not included on the member’s drug list, a formulary exception request would need to be submitted, rather than a PA request, for coverage consideration.) 

Medication Coverage Exclusions – Under the pharmacy benefit, some member’s plans may exclude from coverage the following: weight loss drugs, non-sedating antihistamines, compound medicines, brand-name proton pump inhibitors (PPIs), drugs that have not received FDA approval and prescription drugs with an over the counter (OTC) equivalent available. 

Specialty Drug Changes – Starting Jan. 1, 2017, regardless of plan effective date, HMO individual benefit plans offered on/off the Illinois Health Insurance Marketplace now require the member to obtain self-administered specialty medications from a specialty pharmacy included in the BCBSIL HMO specialty pharmacy network for coverage consideration under the pharmacy benefit. To help your patients receive appropriate benefits, be sure their self-administered specialty medications are filled at a BCBSIL preferred specialty pharmacy. 

Starting Jan. 1, 2017, members with an individual benefit plan offered on/off the Illinois Health Insurance Marketplace who are using a drug manufacturer’s coupon or copay card cannot have the specialty drug payment apply to their plan deductible or out-of-pocket maximum, unless the coupon is a permitted third-party cost sharing payment. Your patients can contact BCBSIL if they have questions about this change. 

Pharmacy Network Changes – Some members’ plans may experience changes to the pharmacy network:

  1. CVS Exclusion – Effective Jan. 1, 2017, CVS pharmacies® and CVS pharmacies in a Target® store were removed from most members’ pharmacy networks.
  2. New Pharmacy Networks – Some members’ plans may move to a preferred network where prescriptions filled at these preferred tiered independently contracted pharmacies offer the lowest copay/coinsurance amounts. 90-day supplies can also be filled at either these preferred tiered pharmacies or through mail order for coverage consideration.

Members who continue to fill prescriptions at a pharmacy no longer in their network will pay more. In most cases, no action is required on your part for any of these pharmacy network changes as members can easily transfer prescriptions to a nearby in-network pharmacy. If your office stores pharmacy information on your patients’ records, you may want to ask your patient which pharmacy is their new in-network choice. 

Retail and Mail Order Supply Limit Changes – Some members’ plans may include a 90-day supply limit for covered prescriptions filled at a retail pharmacy or through mail order. 

If your patients have questions about their pharmacy benefits, please advise them to contact the Pharmacy Program number on their member ID card. Members also may visit and log in to Blue Access for MembersSM for a variety of online resources.

*Changes to be implemented, as applicable, based on the member’s 2017 plan renewal, or new plan effective date, unless otherwise noted. These changes do not apply to members with Medicare Part D or Medicaid coverage.

Prime Therapeutics LLC is a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. In addition, contracting pharmacies are contracted through Prime Therapeutics. The relationship between BCBSIL and contracting pharmacies is that of independent contractors. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.

A “preferred” or “participating” pharmacy has a contract with BCBSIL or BCBSIL’s pharmacy benefit manager (Prime Therapeutics) to provide pharmacy services at a negotiated rate. The terms “preferred” and “participating” should not be construed as a recommendation, referral or any other statement as to the ability or quality of such pharmacy. Please note that changes to participating pharmacies may be made in the future.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. The listing of any particular drug or classification of drugs is not a guarantee of benefits. This is only a brief summary of some plan benefits. For more complete details, including benefits, limitations and exclusions, members should refer to their certificate of coverage. Regardless of benefits, the final decision about any medication and pharmacy choice is between the member and their health care provider.

Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.