Sept. 7, 2016

2017 Pharmacy Benefit Changes for BCBSTX Non-metallic Plan Groups

Blue Cross and Blue Shield of Texas (BCBSTX) reviews the prescription drug benefit program annually to ensure the program is on target with current health care trends, while controlling prescription drug costs for our members. Based on our current review, some changes will be implemented for non-metallic plan groups with prescription drug benefits through BCBSTX and administered by Prime Therapeutics.

Beginning Jan. 1, 2017, these pharmacy benefit changes will be applied upon the group’s 2017 renewal/new plan effective date.*

1. Formulary Changes and Formulary Name Changes

Two new drug lists, also known as a formulary, will be available in 2017. Additionally, the current Standard and Generics Plus Drug Lists’ names will change on Jan. 1, 2017.

Some pharmacy benefit plans will have a formulary change, while others will just have a drug list name change. Some members with a formulary change may be impacted by drugs changing from a preferred status to a higher non-preferred member payment level. Some members may also be impacted by a drug no longer being covered on the drug list. As a reminder, drugs that have not received U.S. Food and Drug Administration (FDA) approval are not covered.

                 2017 Drug List Names

• 2016 Standard Drug List => 2017 Basic Drug List
• 2016 Generics Plus Drug List => 2017 Enhanced Drug List
• Performance Drug List (new for 2017)
• Performance Select Drug List (new for 2017; option available for Administrative Services Only, ASO, groups to select)

2. New Preferred Pharmacy Network

Beginning Jan. 1, 2017, upon a group’s renewal, some pharmacy benefit plans will include a Preferred Pharmacy Network. This network includes at least one major chain, a grocery chain and independent pharmacies, among others. These are the participating pharmacies in the 2017 Preferred Pharmacy Network:

• Walgreens
• Walmart (including Sam’s Club Pharmacy)
• Albertsons (including United Supermarkets)
• HEB
• AccessHealth (a group of independent pharmacies)

When members fill a prescription for up to a 30-day supply of a covered prescription drug from a retail pharmacy that contracts to participate in the Preferred Pharmacy Network, they may pay the lowest copay/coinsurance amount. If members fill a prescription at a non-preferred in-network pharmacy, they may pay a higher copay/coinsurance amount.

For up to a 90-day supply of a covered prescription drug, members can either fill these prescriptions through the home delivery pharmacy service or at a retail pharmacy participating in the Preferred Pharmacy Network. Members will pay 3x copay of one 30-day prescription. A list of all participating pharmacies’ locations will be posted on the bcbstx.com website once available.

Please see the list of changes for your reference.

Letters will be sent to impacted members who are affected by one or more of these changes that will explain how the change(s) will impact them. Members will be encouraged to talk with their doctor(s) about their prescribed medications and if any changes in their drug therapy may be right for them.

ASO groups are encouraged to make these same pharmacy benefit changes.

Stay tuned for more information about these pharmacy benefit changes, including member notifications and other communications. If you have any questions, please contact your BCBSTX representative.

*These pharmacy benefit changes apply for all fully insured standard plan groups that do not have a metallic plan policy. The changes will be implemented on the group’s 2017 renewal/effective date with the following exceptions:
 

• Groups with a grandfathered plan policy or groups on a closed plan (renewal only) policy will only have a formulary name change applied. For example, beginning Jan. 1, 2017, groups whose pharmacy benefits are based on the Standard Drug List will follow the Basic Drug List.
   
• Groups on a custom plan policy will move to the Enhanced Drug List (formerly Generics Plus Drug List). These groups are also encouraged to add the Preferred Pharmacy Network to their pharmacy benefit plan; however, this network change is not required. These groups will also have CVS excluded from the Broad Pharmacy Network on Jan. 1, 2017 (regardless of renewal date).
   
• All standard plans will move to the new Performance Drug List. Groups on a standard plan will also have the Preferred Pharmacy Network added to their pharmacy benefit plan. Additionally, CVS will be excluded from the Broad Pharmacy Network on Jan. 1, 2017 (regardless of renewal date).
   
• Small groups on a metallic plan, offered on or off the Exchange, will remain on their current formulary. Members may be impacted by annual changes to the list of covered drugs. Effective Jan. 1, 2017 (regardless of renewal date), these groups will have the following pharmacy network changes: CVS excluded and changes to the participating pharmacies in the 2017 Preferred Pharmacy Network.

Prime Therapeutics LLC is a pharmacy benefit management company. Blue Cross and Blue Shield of Texas (BCBSTX) contracts with Prime Therapeutics to provide pharmacy benefit management and other related services. BCBSTX, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.