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Blue Cross Pharmacy Benefit Changes

Blue Cross Blue Shield

Effective Jan. 1, 2011, Blue Cross and Blue Shield of Louisiana and our subsidiary, HMO Louisiana, Inc. (collectively referred to herein as “Blue Cross”) will implement changes to the copayment tiers that are part of your clients’ pharmacy benefit plan. This will involve moving several prescriptions to a different tier, or copayment level. Blue Cross will also implement changes to the drugs that require a prior authorization, as well as those that are part of our Lead with Genericsprogram.  These changes have been approved by the Blue Cross Pharmacy and Therapeutics (P&T) Committee, a group of Louisiana doctors and pharmacists.

Copayment Tier Changes
Throughout each year the P&T Committee regularly reviews available safety, efficacy and cost information on prescription medications. This year the committee recommended changing the copayment tier for several drugs.  For example, in 2010, the copayment tier for the following drugs was changed from the higher Tier 3 copayment level to the lower Tier 2 copayment level: Embeda®, Focalin® XR,  Lumigan®, Onglyza™ and Welchol™. Members taking one of these medications may have received the benefit of this lower copayment savings in 2010.

In addition to recommending some brand-name drugs be moved to a lower copayment tier, the P&T Committee occasionally recommends moving other medications to a higher copayment tier. The drugs that will require a Tier 3 copayment effective January 1, 2011, as well as lower Tier 2 and Tier 1 copayment alternatives are provided below:

 

Pharmacy Copayment Tier Changes Effective Jan. 1, 2011

Tier 3 Medication
(Higher Copayment)

Tier 2 Alternatives
(Middle Copayment)

Tier 1 Alternatives
(Lowest Copayment)

Avandamet®, Avandaryl®, Avandia®

Actoplus Met®, Actoplus Met® XR, Actos®, Duetact®

 

DynaCirc® CR

 

amlodipine, felodipine ER

FemHRT®

Premphase®, Prempro®

estradiol-norethindrone

Vesicare®

Enablex®, Sanctura® XR

oxybutynin, oxybutynin ER, trospium

 

We encourage our members to discuss these changes and the lower copayment alternative (Tier 2 and Tier 1) medications with their physicians. 

Prior authorization changes 
Members must obtain prior authorization for certain prescription drugs to ensure appropriate drug coverage. On Jan 1, 2011, we will add drugs to our prior authorization program.  If members begin taking any of these medications, a prior authorization will be required.  

The additional drugs that will require a prior authorization effective Jan. 1, are provided below:

If members are already taking one of the new medications that will require prior authorization effective Jan. 1, 2011, they will not be required to have their physician provide a prior authorization.

Lead with Generics
On Jan. 1, we will make changes to our Lead with Generics program, which promotes the use of generic drugs as the first step in treating a medical condition. With this program, members are required to try a generic option or similar alternative medication (in certain drug classes) before using a brand-name drug. If members are prescribed any of these medications on or after Jan.1, they may be required to try a generic first.

The additional drugs that will require a trial with a generic option or similar alternative medication are provided below:

If members are already taking a brand-name medication in the Lead with Generics program, they will not be required to change to the generic alternative.

Group leaders will be notified of this change next week. Members and targeted physicians will be notified the following week. Physicians will receive lists of the patients for whom they have prescribed drugs that will require higher copayments beginning January 1, 2011. In addition, members who have been prescribed medications that are affected by these copayment changes will be targeted for a separate mailing informing them of the specific changes.

To help our customers more effectively manage healthcare costs, Blue Cross is asking physicians to consider drugs with lower copayments when they believe it is appropriate for their patients. Likewise, to keep members’ out-of-pocket expenses as low as possible, we want to make sure that they are informed of the changes, and we are encouraging them to discuss their prescription medications with their physicians.