2010 Prescription Drug Program Changes [Group Markets]

To encourage safe, cost-effective medication use and help control pharmacy trends, Blue Cross and Blue Shield of Illinois (BCBSIL) is making some prescription drug benefit program changes effective for new groups or upon renewal on or after January 1, 2010.

For HMO Groups and Non-HMO Standard Products
Prior Authorization/Step Therapy Program Additions
The following drugs/drug categories will be added.

Prior Authorization (PA): Designed to promote patient safety and use of the drug as intended by the manufacturer and the U.S. Food and Drug Administration (FDA), this program helps reduce the potential for medication misuse and abuse, and encourages cost-effective medication use. PA requires the member’s physician to obtain authorization from BCBSIL before the member can receive coverage for certain medications and drug categories. In the event that prior authorization is not obtained, the member will then be responsible for the first $1,000 or 50 percent of the Eligible Charge per prescription, whichever is less.

Both the Solodyn^®* drug and narcolepsy drug category will be added to the PA program.

Targeted mailings will be sent to members affected by the additions to the PA program at least 60 days prior to the implementation date.

Step Therapy (ST): This program is designed to encourage the initial use of alternative medications generally recognized as safe and effective, which are also lower cost. To receive coverage, the member may need to first try a proven, cost-effective medication before progressing to a more costly treatment, if necessary. After the member has a prescription history for a lower-cost alternative medication, coverage will automatically be provided for a more costly medication that is included in the program.

The additional ST categories are automatically included for new groups with effective dates on or after 1/1/10. For renewing groups (groups with prescription drug benefits through BCBSIL prior to 1/1/10), all initial claims submitted for a drug included in these categories after the renewal date will be processed under the program. Continued coverage will be provided for members who have a claims history for a drug included in these categories prior to 1/1/10.

Three drug categories will be added to the ST program: cholesterol, osteoporosis and proton pump inhibitors.      

Lancets Available for $0 Member Share
To assist members in monitoring their blood glucose levels, also effective 1/1/10 for all HMO and non-HMO fully insured groups with prescription drug coverage through BCBSIL, there will be a $0 member share for lancets. To receive coverage, the member will need to present a prescription at a contracting pharmacy.

For ASO Groups Only
Mandatory Mail Service Program
Self-funded groups with prescription drug coverage through BCBSIL may want to consider adding a mandatory mail service program to their benefit to further help manage pharmacy costs. Mandatory mail requires members to obtain maintenance medications through PrimeMail^®’ Pharmacy** in order to receive benefits. Members will have coverage at a retail pharmacy for their first two fills of maintenance medication. After the second fill, members must obtain the medication through PrimeMail to receive coverage.

All Groups
Dispensing Limit Changes
BCBSIL’s standard prescription drug benefit program includes coverage limits on certain medications and drug categories. Dispensing limits are based on FDA-approved dosage regimens and product labeling.

Also effective 1/1/10, a 30-day supply limit will be implemented for all groups for the following specialty drug categories, listed along with sample drugs*:

• Multiple sclerosis (Avonex, Betaseron, Copaxone, Rebif)
• Biologic immunomodulators (Cimzia, Enbrel, Humira, Kineret, Simponi)

For a list of drug dispensing limits, visit www.bcbsil.com/rx/pdf/drug_dispensing_limits_2009.pdf.

Targeted mailings will be sent to members affected by the changes in dispensing limits at least 60 days prior to implementation.  

If you have questions about these changes, or are interested in discussing mandatory mail, contact your BCBSIL representative.

* Third party brand names are the property of their respective owners.
 
** PrimeMail Pharmacy is a mail order pharmacy owned and operated by Prime Therapeutics LLC, a pharmacy benefit management company. Blue Cross and Blue Shield of Illinois contracts with Prime Therapeutics to provide pharmacy benefit management and mail order pharmacy services. Blue Cross and Blue Shield of Illinois, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.