Reminder: Pharmacy Program Benefit Changes – Effective January 1, 2017

May 3, 2017

Blue Cross and Blue Shield of Texas (BCBSTX) implemented pharmacy benefit changes as of January 1, 2017, for some members with prescription drug benefits administered through Prime Therapeutics.*

Based on claims data, letters are sent from BCBSTX 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 listing all 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 BCBSTX. Your patient may also 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. 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. 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 FDA approval are not covered under the BCBSTX 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 select medications included in these programs, he/she 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.

Specialty Drug Changes – Starting January 1, 2017, members with an individual benefit plan offered on/off the Texas Health Insurance TX Marketplace who are using a drug manufacturer's coupon or copay card will not 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 BCBSTX if they have questions about this change.

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

  1. CVS Exclusion – Effective January 1, 2017, CVS pharmacies® and CVS pharmacies in a Target® store were removed from most members' pharmacy network.
  2. New Pharmacy Networks –Some members' plans may move to a preferred network where prescriptions filled at these preferred tiered 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 choice.

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 (BAMSM) 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. BCBSTX 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 BCBSTX and contracting pharmacies is that of independent contractors. BCBSTX, 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 BCBSTX or BCBSTX'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. 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 and pharmacy choice is between the member and their health care provider.