Pharmacy Program Benefit Changes – Effective Jan. 1, 2016

Blue Cross and Blue Shield of Texas (BCBSTX) will be implementing pharmacy benefit changes as of Jan. 1, 2016, for some members with prescription drug benefits administered through Prime Therapeutics.*

Based on claims data, letters will be sent from BCBSTX to alert members who may be taking, or who may have been prescribed, a medication that may be affected by the 2016 pharmacy benefit changes. A summary of the changes, as outlined in the member letters, is included below for your reference.

Drug List Changes – Some members’/subscribers’ plans may now be based on the Generics Plus Drug List. As a result, select medications will move to a higher copay/coinsurance payment tier.

Medication Coverage Exclusions – Most brand-name proton pump inhibitor (PPI) drugs will no longer be covered under the member’s/subscriber’s pharmacy benefit. Select drug classes and/or brand-name drugs may also no longer be covered under the member’s/subscriber’s pharmacy benefit. As a reminder, medications that have not received FDA approval are not covered under the BCBSTX pharmacy benefit.

Specialty Drug Changes – Some members’/subscribers’ plans may require the member//subscriber to obtain self-administered specialty medications from a specialty pharmacy included in the BCBSTX preferred specialty network. If the member/subscriber does not use the preferred specialty network, they will pay the specialty copay/coinsurance, based on their benefit, plus an out-of-network fee.

Starting Jan. 1, 2016, the BCBSTX preferred specialty network will be expanded to include additional oral oncology and hemophilia specialty pharmacies, including Prime Therapeutics Specialty Pharmacy. For members with an individual benefit plan offered on/off the Texas Health Insurance Marketplace, self-administered specialty medications will move to a coinsurance amount rather than a fixed copay (i.e. $150 in 2015). To help your patients receive the highest level of benefits, be sure their self-administered specialty medications are filled at a BCBSTX preferred specialty pharmacy.

Utilization Management Program Changes – Some members’/subscribers’ plans may now be subject to new prior authorization and step therapy programs and/or dispensing limits. Members/Subscribers taking select medications included in these programs may need to meet certain criteria, such as an approval of a prior authorization request, for coverage consideration.

New Preferred Pharmacy Network – For members/subscribers with an individual or employer-offered benefit plan offered on/off the Texas Health Insurance Marketplace, this new pharmacy network will offer the lowest copay/coinsurance amounts. Members/Subscribers filling prescriptions at a non-preferred in-network pharmacy may pay a higher copay/coinsurance amount.

Please note: prescriptions filled at a retail pharmacy for a 90-day supply must be filled at either a pharmacy in this new network or through mail order for coverage consideration.

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

*Changes to be implemented, as applicable, based on the member’s/subscriber’s 2016 plan renewal, or new plan effective date. These changes do not apply to members/subscribers 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. BCBSTX, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a registered trademark of 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/Subscribers 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/subscriber and their health care provider.