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. Continue reading “Blue Cross 2017 Pharmacy Benefit Changes”

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Changes Happening to the 2017 Humana Drug Lists

Starting January 1, 2017,* some of the medicines covered by Humana’s prescription drug plan may change. 

What do these changes mean? Some medicines will have new requirements. (Specific state regulations may apply.) These requirements include:

  • Prior Authorization: The member’s doctor must contact Humana to get approval before he or she fills or refills a prescription for any medicine that requires prior authorization. His or her plan benefits won’t cover this medicine without prior authorization, and he or she will pay the entire cost of the medicine if he or she decides to buy it.
  • Step Therapy: Sometimes there’s more than one medicine that works to treat a health condition. Some medicines may cost less but work just as well. Before a prescription is filled for a medicine that costs more, the member may be asked to try at least one other medicine first.

If the member’s doctor thinks the other medicine isn’t right for him or her, he or she will need to request approval from Humana to use the medicine that costs more. His or her plan benefits won’t cover this medicine without approval, and he or she will pay the entire cost of the medicine if he or she decides to buy it.

  • Quantity Limits: A member has a limit on the amount of some medicines he or she can fill during a period of time. These limits can be placed on some drugs because of safety concerns and help prevent misuse of these drugs. If the member’s prescription is over the limit, there are two choices:He or she can get the amount of medicine that’s covered by his or her plan benefits and then pay out of pocket for any medicine that’s over the limit.

OR If his or her doctor thinks more medicine is needed, he or she can ask for approval from Humana for the amount of medicine that goes over the limit.

  • Tier Changes: The member’s medicine(s) is grouped into different tiers. For each tier, he or she will pay a different amount. If a member fills or refills a prescription for a medicine that’s moving to a different tier, he or she may have to pay more or less.
  • Not Covered: Starting January 1, 2017,* some medicine(s) will no longer be on the member’s Drug List. If a member fills or refills a prescription for any medicine that isn’t covered under his or her benefit plan, he or she will have to pay the full cost of the prescription.

The member’s doctor can ask Humana to make an exception to cover his or her drug if it’s not on our Drug List. Generally, Humana will only approve a request for an exception if the alternative covered drugs wouldn’t be as effective in treating his or her health condition and/or would cause adverse medical effects. To ask for an exception, the doctor can contact HCPR at 1-800-555-2546 between 8 a.m. – 6 p.m., Monday – Friday.

Why is Humana making these changes? 
Humana reviews and updates the Drug List to help ensure safety and offer cost-effective choices for drug benefits. Updates to the drug list can happen when medicines have changes in dosing and prescribing guidelines. The selection of available medicines may also change. This can happen when a drug is removed from the market by the Food and Drug Administration (FDA) or a drug’s manufacturer, or a new drug becomes available and is added to the drug list.

Next steps
Visit Humana.com/Druglist after October 15, 2016 to review the latest Drug Lists and changes in 2017. If you have questions, please contact your Humana Sales Representative.

Humana clients and their employees will receive notification from us explaining these changes.

*For Texas, Louisiana, and Puerto Rico Fully Insured groups, these changes start on each group’s renewal date in 2017

Special Enrollment period

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You may be eligible to enroll for insurance even after the January 31st deadline if you qualify for the special enrollment period. The special enrollment period is a period outside of open enrollment where you can get insurance coverage due to qualifying life events.

You may qualify for the special enrollment period if you have:

  • Married or divorced
  • Moved to another state
  • Had a baby or adopted a child
  • Changed jobs
  • Had changes in your income that affect the coverage you qualify for
  • Became a U.S. citizen
  • Left incarceration
  • Had a change of dependency status of someone on your plan
  • Had a death of a covered member of your household
  • Turned 26 and aged off your parent’s plan
  • Lost employer group coverage

Special Enrollment Periods

The 2015 Annual Open Enrollment period has come to a close. Individuals are now limited on when and how often they are able to purchase an individual policy until the next Annual Open Enrollment period begins. Annual Open Enrollment for 2016 is currently scheduled for Nov. 1, 2015 through Jan. 31, 2016.

Individuals may be eligible for a special enrollment period if they experience a qualifying life event. Applicants may apply for coverage either On- or Off- Exchange.

OFF-Exchange Special Enrollment Periods:

To apply for coverage outside of Annual Open Enrollment, individuals must experience a qualifying life event listed below. Unless specifically stated otherwise, a qualified individual or enrollee has 60 days from the date of the triggering event to select a Health Plan.

COMMON QUALIFYING LIFE EVENTS INCLUDE:

  • Marriage
  • Birth or Adoption
  • Divorce
  • Relocating
  • Losing minimum essential health coverage
  • Loss of employer-sponsored health coverage
  • Loss of coverage for a dependent
  • Death of the policy holder
  • Cobra expiration
  • Medicaid or CHIP Expiration
  • Health plan decertified
  • No longer incarcerated
  • Gaining status as a citizen, national or lawfully
  • Change in income that results in an individual determined newly eligible or newly ineligible for tax credits
  • Change in eligibility for cost-sharing reductions
  • Return from active military service

A Special Enrollment Period Authorization Form MUST ACCOMPANY THE INDIVIDUAL APPLICATION for consideration of an off-Exchange special enrollment period. The individual will receive a first-of-the-month affective date following the processing of the application.

ON-Exchange Special Enrollment Periods:

According to Healthcare.gov, individuals may buy a private health plan through the Marketplace outside Annual Open Enrollment only if they qualify for a special enrollment period due to a qualifying life event such as marriage, birth, or adoption of a child, or loss of other health coverage.