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Microsoft word - plan admin notification-rx changes-fully insured-premier formulary-final-1.docx
Important Information Regarding Blue Cross & Blue Shield of
Rhode Island’s Prescription Drug Program
Blue Cross & Blue Shield of Rhode Island (BCBSRI) is committed to providing the highest quality healthcare coverage at the most affordable price. In light of this goal, we are changing our prescription drug coverage to help you and your employees get the most value from your health plan. There are several components of our pharmacy benefits that are aimed at meeting this goal. These include:
BCBSRI will continue to use a tiered formulary. The second tier of our formulary will now also contain several high cost generic drugs. These drugs are generally new on the market, and in most cases do not yet have any competition from other generics. As a result, they continue to be priced comparable to their brand drug equivalent. BCBSRI will continue to review and update our formulary, and will move these drugs down to a tier 1 position as marketplace changes warrant.
Having a tiered formulary in place has been proven to encourage the use of effective, cost-
Value Driven Drug Alternatives
Another major component of BCBSRI’s efforts to control costs is excluding drugs that have viable generic equivalents and/or over-the-counter alternatives from our formulary. These drugs are just as effective as brand name drugs, without the cost.
Increasing generic drug utilization will save both members and employers thousands of
Ensuring Appropriate Drug Utilization
Prior authorization is the process used to promote the most clinically appropriate, and cost effective therapy. The goal is to make physicians more aware of lower cost alternatives. Authorization also helps counter the consumer response to prescription drug advertisements. These ads may convince members they need a specific medication, even if it is not appropriate or necessary for their condition.
Prior authorization helps ensure members receive the right drugs for the right conditions.
The following summary illustrates the changes occurring as a result of the new formulary. Our new formulary is named Premier and goes into effect starting on November 1, 2010.
Generic Drugs in the Second Tier
The following high cost generic drug products will now require a second tier copayment:
Benz Perox/Erythromycin (Benzamycin®)
Clindamycin/Benz Perox (Benzaclin®)
Dextroamphetamine XR (Adderall XR®)
In addition, most generic benzoyl peroxide and sulfacetamide products used for treatment of Topical Acne will require a second tier copayment.
The following categories of drugs will experience a change in tier status.
Anticonvulsants, thyroid, and oral transplant brand name drugs
with generic equivalents are moving from Tier 2 to Tier 3
Abilify is moving from Tier 2 to Tier 3
All brand name contraceptive drugs (e.g. Ortho Tri-Cyclen Lo, All Oral
YAZ, Ortho Evra, and Nuvaring) are moving to Tier 3
All brand name opthalmic allergy products (e.g. Pataday,
Patanol) are moving to Tier 3
Nuvigil is moving from Tier 3 to Tier 2.
Provigil is moving from Tier 2 to Tier 3.
Dexilant is moving from Tier 3 to Tier 2
Prior Authorizations (for Managed Plans)
The following categories of drugs will experience additional requirements for Prior Authorization
Prior Authorization Changes
Required for Lamictal, Topamax, and Keppra.
The following categories of drugs will no longer be covered
under the prescription drug benefit
program. Drugs that are excluded from coverage are not eligible for an exception process for
coverage, and a member’s provider cannot call for an authorization.
Excluded from Coverage
All brand name drugs (e.g. Clarinex, Allegra, Allegra D, Non-Sedating Oral Agents
All brand name drugs (e.g. Trilipix, Tricor)
Fibric Acid Derivatives
All brand name drugs (e.g. Aczone, Benzaclin, Differin, Acne Products (oral/topical)
All brand name drugs (e.g. Oracea, Monodox, Noritate)
All brand name drugs (e.g. Ambien CR, Lunesta, Sonata)
All brand name drugs (e.g. Doryx, Solodyn)
All brand name and generic drugs (e.g. Nexium, Aciphex, Prevacid, Prevpac, Zegerid, Lansoprazole, Pantoprazole).
Except for: Omeprazole (20mg in Tier 1), Dexilant (in Tier 2) and Prevacid Solu-tab for children under 5 years old (only in Tier 3.)
In addition, all multi-source brand name drugs with generic or over-the-counter equivalents will be excluded from coverage, however brand name drugs in the following categories are covered: anticonvulsants, thyroid, oral transplant medications and stimulants for ADHD.
Other important information: Why are some generics expensive?
• Pharmaceutical companies typically inflate the price of the brand name drug in the last 6-8
• When the generic first comes to the market, it is 10% lower than the cost of the brand
– Example: Brand Name Drug X = $200 – Generic of Brand X = $180
• Depending on the drug, there may be only one generic available for a period of time (6-18
months), which keeps the cost of the generic high and only slightly less than the brand.
• National industry standard to tier generics based on average cost per month, no longer
How will my employees be notified?
• All plan subscribers will receive a notification in the mail of the formulary changes.
• Members who will be directly impacted by the changes will receive a personalized
disruption letter detailing how their prescriptions will be effected.
• All plan subscribers will receive an educational mailer describing what BCBSRI and
members can collectively do to curb prescription drug costs.
Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.
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Specialty Pharmacy Provider:________________ Date: ___________ Date Medication Required:____________ Phone: (855) 535-1815 Ship to: Physician Patient’s Home Other __________ Fax: (855) 815-9894 Prior Authorization Form Juxtapid Patient Name: ___________________________________________________ Physician Name: _______________________________________________ Ad