Guide to Changes in Drug Coverage for Fully Insured Members in 2017
In 2017, Blue Cross and Blue Shield of Louisiana will implement a closed formulary for non-grandfathered individual and non-grandfathered small group (2-50) plans and make annual formulary updates to drug coverage for all other members.
New covered drug list:
Affected Members: non-grandfathered individuals and non-grandfathered small group plans
Today, the Blue Cross formulary is open for all members. This means Blue Cross cover all contract-eligible prescription drugs at different cost-share levels. Starting Jan. 1, 2017, drug lists for non-grandfathered individual and non- grandfathered small group (2-50) plans will be closed. This means Blue Cross will not cover every drug, only those on the list.
For individual benefit plans only, 4-Tier pharmacy benefit plans are moving to a new 3-Tier pharmacy benefit design. See the charts below for details.
Drug companies making dramatic and sudden price changes.
The average price for the most commonly used brand-name drugs has increased 164% since 2008, while generic drug prices have continued to decline.
Due to manufacturer price hikes, a common brand-name drug that cost $100 in January 2008 costs more than $264 in December 2015. In the same time-frame, a common generic medication dropped in price from $100 to $29.73.
In contrast, a market basket of household goods that cost $100 in January 2008 grew to only $112.05 at 2015’s end.
Annual Formulary Updates
Affected Members: All grandfathered individual and group members and non-grandfathered large groups.
- Changes in tiers for some drugs.
- Additional drugs needing prior authorization.
- Drugs added to the quantity per dispensing limit list.
- Additions to the specialty drug program.
Updated open formulary drug lists will be available online by Dec. 16, 2016.
Updated Contract Exclusions
Affected Members: All fully insured members
Selected drugs with over-the-counter alternatives will not be covered.
Selected drug kits that include or are packaged with a non-prescription product will not be covered, but the prescription drug may be covered when purchased alone.
Medical marijuana is excluded from coverage today for all benefit plans. A clarifying exclusion will be added to 2017 contracts.
Two things members should do to get the most out of their benefits:
- Check to see if the drugs they take are on the drug list. Go to bcbsla.com/pharmacy for the list of covered drugs. The list will be online Nov. 1, 2016.
- Talk to their doctors about switching to a drug that is on the list, if needed.
If a member cannot take any of the covered drugs:
- If there is a medically necessary need for a drug that is not on the covered drug list, doctors may request coverage.
- Certain criteria must be met before the drug may be covered. If those criteria are not met, the member will have to fill a covered alternative or pay full price for a drug not on the list.
If an individual or small group member fills a prescription for a drug that is not on the covered drug list:
- If members fill a prescription for a drug that is not on the covered drug list, they could have to pay the full cost of the drug out of pocket.
- For the first 90 days after their renewal or effective date, members may get a one-time fill (up to a 30-day supply) of a drug that is not on the covered drug list. Then he or she will get a letter from Express Scripts telling them that the drug will not be covered next time. The member’s doctor will get a similar letter.
When can you see the new covered drug list?
The new covered drug list will be available at bcbsla.com/pharmacy by Nov. 1, 2016.