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Prescription Drug Benefit Changes for 2016 Individual or Employer-offered "Metallic" Plans

Oct. 23, 2015

If you have a Blue Cross and Blue Shield of Texas (BCBSTX) "metallic" health plan now, either purchased on your own or offered through your employer, some changes will be made to the prescription drug benefits. You can use this information when making your health plan selection(s) during Open Enrollment for 2016.

Starting January 1, 2016, these changes will be made:*

Preferred Pharmacy Network

A Preferred Pharmacy Network has been added to the prescription drug benefit plan. When you fill a prescription for up to a one-month supply from a preferred pharmacy, you will pay the lowest copay/coinsurance amount. If you fill a prescription at a non-preferred pharmacy, you may pay a higher copay/coinsurance amount.

You can also fill up to a 90-day supply of prescription drugs at a retail pharmacy in the preferred pharmacy network.

Preferred Pharmacies in your network are:

  • CVS
  • Walmart (also known as Sam's Club Pharmacy)
  • HEB
  • Brookshire's (also known as Super1Pharmacy)
  • 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 "Health Insurance Marketplace Network" and filtering for preferred pharmacies.

Drug List Changes

Some brand drugs are changing from a preferred brand (Tier 3) to a non-preferred brand (Tier 4) status. Also, some generic drugs will move from a preferred generic (Tier 1) to a non-preferred generic (Tier 2) status. These drugs will still be covered. But you may have to pay a higher copay or coinsurance amount, based on your benefit plan. Please note: Some health plans also changed the member share (copay or coinsurance amount) on specialty drugs (Tier 5). Check your benefit materials for details.

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.

Below is a table showing the top most often used brand drugs that are being moved. You can view a list of their covered alternatives PDF Document. Or, 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.

Top Most Often Used Drugs Moving from Preferred Brand (Tier 3) to Non-Preferred Brand (Tier 4)**

Vyvanse Advair Diskus Lyrica
Pataday Voltaren Lialda
Benicar Colcrys Xarelto
Prednisone Solution Androgel Pump Lotemax
Dulera Suboxone Vesicare
Ciprodex Vigamox Benicar HCT
Linzess Lumigan  

Drugs No Longer Covered

Select brand-name products will no longer be covered under the prescription drug benefit. A covered generic or brand alternative drug may be available. If you are taking, or are prescribed, one of these brand drugs that will no longer be covered, ask your doctor if a generic or lower cost preferred brand alternative drug is right for you. Some of these alternative drugs may call for prior authorization or have a dispensing limit before they can be covered.

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**

Nasonex Atralin Armour Thyroid
Astepro Epiduo Treximet
Triamcinolone spray Clobex Lovaza
Zutripro Accu-Chek test strips Cymbalta
Aczone Focalin XR Acanya
Adderall XR Ziana Zipsor
Vivelle-Dot Donnatal Duexis
Cytomel Zorvolex Differin
Vimovo    

Certain drugs will also not be covered if they do not have the U.S. Food and Drug Administration's (FDA) approval. See a sample list of these types of drugs PDF Document.

Utilization Management Programs Added

New prior authorization and step therapy programs are being added to the 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 BCBSTX 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.

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. 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 2016 plan renewal date.

** Third party brand names are the property of their respective owners.