Affected Members: Non-grandfathered individuals and small groups (2- 50 employees)

• Today, our formulary is open for all members. This means we cover all contract-eligible prescription drugs at different cost share levels. Starting Jan. 1, 2017, drug lists for non-grandfathered individuals and small groups (2- 50 employees) will be closed. This means we will not cover every drug, only those on the list.

If an individual or small group member fills a drug that is not on the covered drug list:

• If members fill 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 transition fill of a non-formulary drug up to a 30-day supply. Then he or she will get a letter from Express Scripts explaining that the drug will not be covered next time. The member’s doctor will receive a similar letter.

If a member cannot take any of the covered drugs:
Doctors may request coverage of a non-formulary drug if there is a medically necessary need for a drug that is not on the covered drug list. 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.

Sample communications about closed formulary:

• Sample group leader letter to small groups moving to a new covered drug list (closed formulary)
• Sample member letter to those who will move to a new covered drug list
• Sample member education (brochure) about the new covered drug list
• Sample letter to members who received their one-time transition fill of a non-covered drug

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.

Affected Members: Non-grandfathered individuals

• 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.

Affected Members: All grandfathered individual and group members and non-grandfathered large groups (51+)

• Drugs That Will Change Tiers and Copay Costs in 2017 (5-Tier Example)
• Prior Authorization Additions (open formulary)
• New Quantity per Dispensing Limits
• Specialty Drug Additions. (See sample member letter link below.)

Sample communications about annual formulary update:

• Sample letter to group leaders with annual open formulary updates
• Sample letter to members with annual open formulary updates
• These samples include all changes, but not all changes will apply to every pharmacy benefit plan. Each annual formulary update letter will include only the changes that apply.

When can you see the updated open formulary?

• Updated open formulary drug lists will be available online by Dec. 16, 2016.

Affected Members: All fully insured members

• Select Prescription Drugs with Over-the-Counter Options Excluded from Coverage
• Select Prescription Drug Kits Excluded from Coverage
• Medical marijuana is excluded from coverage today for all benefit plans. A clarifying exclusion will be added to 2017 contracts.

Producers will be given these documents to help them speak to their fully insured clients about why we are making these changes. Some may have gotten them at the recent Sales Caravans.

• Brokers Guide to the 2017 Covered Drug List
• Brokers Guide to Changes in Drug Coverage

Affected Members: All members with Express Scripts* administered pharmacy benefits through Blue Cross or HMO Louisiana.

• Drugs That Will Change Tiers in 2017 (3-Tier Example)
• Prior Authorization Additions (Standard ASO Example)
• New Quantity per Dispensing Limits
• Specialty Drug Additions (See sample member letter link below.)

Sample communications about annual formulary updates:

• Sample letter to group leaders with annual open formulary updates
• Sample letter to members with annual formulary updates
• These samples include all changes, but not all changes will apply to every pharmacy benefit plan.

Affected Members: All members with Express Scripts administered pharmacy benefits through Blue Cross or HMO Louisiana.

• Medical marijuana is excluded from coverage today for all benefit plans. A clarifying exclusion will be added to 2017 contracts.

Affected Members: All members with Express Scripts administered pharmacy benefits through Blue Cross or HMO Louisiana.

• A group must choose all or none of these exclusions:
• Select Prescription Drugs with Over-the-Counter Options Excluded from Coverage
• Select Prescription Drug Kits Excluded from Coverage
• Select Prescription Combination Drugs Excluded from Coverage
• Groups will get more information about these exclusions in the Notice of Plan Change document included in their renewal packets.

We are pleased to say that the goal of this program has been met. Today, 85 percent of prescriptions filled are generics. The cost-saving function of this program will be continued through our provider partnership programs going forward. For those reasons, we will sunset the First Fill for Free program as of Jan. 1, 2017.

We will notify self-funded groups that have this option about the program’s end before Jan. 1, 2017.