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Pharmacy Program Updates: Quarterly Pharmacy Changes Effective on or after July 1, 2020 – Part 1

Posted April 15, 2020

DRUG LIST CHANGES

Based on the availability of new prescription medications and Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some revisions (drugs still covered but moved to a higher out-of-pocket payment level) and/or exclusions (drugs no longer covered) will be made to the Blue Cross and Blue Shield of Illinois (BCBSIL) drug lists. Your patient(s) may ask you about therapeutic or lower cost alternatives if their medication is affected by one of these changes. The list of these changes was communicated in the previous April 2019, July 2019, October 2019 and January 2020 quarterly pharmacy changes articles.

Please Note: The health, safety and well-being of our members and the communities we serve is our top priority. Due to novel coronavirus 2019 (COVID-19), we will delay the start date of these annual drug list changes until October 1, 2020 for members identified for notification based on claims filled between Nov. 13, 2019 and March 13, 2020. This will allow your patients more time to safely talk about these changes with you and together decide the best choices for them.

The Quarterly Pharmacy Changes Part 2 article with more recent coverage additions will also be published closer to the July 1, 2020 effective date.

UTILIZATION MANAGEMENT PROGRAM CHANGES

  • Effective April 15, 2020, the Peanut Allergy Specialty Prior Authorization (PA) program will be added for standard pharmacy benefit plans and all prescription drug lists. This program includes the newly FDA-approved target drug Palforzia.
  • Effective July 1, 2020, the Oxbryta Specialty PA program will be added to the Balanced, Performance, Performance Annual and Performance Select Drug Lists. This program includes the target drug Oxbryta.

Per our usual process of member notification prior to implementation, targeted mailings were sent to members affected by annual drug list revisions and/or exclusions, annual dispensing limit and annual prior authorization program changes. For the most up-to-date drug list and list of drug dispensing limits, visit the Pharmacy Program section of our Provider website.

If your patients have any questions about their pharmacy benefits, please advise them to contact the number on their member ID card. Members may also visit bcbsil.com and log in to Blue Access for MembersSM (BAMSM) or MyPrime.com for a variety of online resources.

HSA Preventive Drug Program Updates
Select members’ Health Savings Account plans may include a preventive drug program, which offers a reduced cost share for members using certain medications for preventive purposes.

Please call the number on the member’s ID card to verify coverage, or for further assistance or clarification on your patient’s benefits.

Prime Therapeutics LLC is a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management and related other services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. MyPrime.com is an online resource offered by Prime Therapeutics.

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. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.