Blue Cross 2017 Pharmacy Benefit Changes

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:

  1. Check to see if the drugs they take are on the drug list. Go to for the list of covered drugs. The list will be online Nov. 1, 2016.
  2. 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 by Nov. 1, 2016.


Check out this great post by Michael Bertaut for more information about why pharmacy costs are going through the roof: Can You Afford Your Miracle




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