Individual Business Prescription Drug Utilization Management Changes Frequently Asked Questions Overview: Up to six prescription drug utilization/benefit management (UM) programs will be added to the individual plans in Illinois, Oklahoma, New Mexico and Texas. We have implemented these changes designed to help our members manage their prescription drug benefits and maximize their coverage when the need for prescription drugs arises. These changes are effective 1/1/12 in Illinois, New Mexico and Oklahoma for all existing non-grandfathered and new members. The programs will begin marketing 11/1/11 for 1/1/12 effective dates. Texas will be effective 3/1/12 for new business only. The Texas programs will begin marketing 1/1/12. Please see the chart below for benefits in each state. Only the non-grandfathered plans will have the Rx UM programs added. Furthermore, the Temp/Short-term plans, Simply Blue and Blue Pathway will not receive the Rx utilization/benefit management programs. Blue Pathway already has been set up with the Rx management programs. Rx Utilization Management Benefits by State Rx UM Program Illinois (eff. 1/1/12) Oklahoma (eff. 1/1/12) New Mexico* (eff. 1/1/12) Texas** (eff. 3/1/12) Step Therapy Quantity Limits Prior Authorization Member Pay the Difference (HSA Plans Only already exist for copay Rx plans) Specialty Pharmacy Program Mandatory Mail for Maintenance Drugs * Please note: New Mexico Blue Direct members currently have five of the six programs already in place; the New Mexico HSA plan has four of the six programs in place. ** Texas currently marketed individual plans have the Member Pay the Difference program. Rx UM FAQs October 26, 2011 Page 1
1. Why are changes being made to the Rx UM Programs? We have implemented changes designed to help members manage prescription drug benefits and maximize their coverage when the need for prescription drugs arises. 2. Will members receive a new ID card? IL: A new ID card with prescription drug information will be issued for those members who are in a plan that is converting from requiring the member to pay upfront, the entire cost of their prescriptions, and then being reimbursed (Blue Script), to only requiring the member to pay the coinsurance portion upfront. OK: A new ID card will be issued for all members in a non-grandfathered HealthCheck (and Personal Blue) plan that is converting from requiring the member to pay up-front, the entire cost of their prescriptions and then being reimbursed, to only requiring the member to pay the coinsurance portion upfront. With this change, all non-grandfathered BCBSOK members whose drug benefits are currently being administered by BCBSOK will be administered by Prime Therapeutics, creating a need for new ID cards. (Prime information needed by the pharmacist will be printed on the new cards e.g., BIN number.) The only change the members will see is that they now only pay the copay/coinsurance amount up-front. The behind the scenes administration of the benefits will not affect the members coverage. The new ID card will also reflect the change from Stop Loss to OP. NM/T: New ID cards will not be reissued for New Mexico or Texas members. 3. What should the member expect when they go to the pharmacy for prescriptions? OK/IL: In order to implement the programs in IL and OK, some members will see a change in the way their transaction works at the retailer. If the member was previously paying full price for their prescriptions, they will no longer be required to pay the whole amount at the point of sale and be reimbursed the amount that BCBS covers. The member will now present their new ID card/prescription drug card when they present their prescription. They will only have to pay the copayment/coinsurance that applies to their policy. The member will receive an information packet with a copy of a new Rx Utilization Management rider that will provide them this information. If the member provides their group number to the FSU representative, the representative can tell them how they are impacted. This number can be found on the front of the member s ID card. There will not be any changes if the member was already using a drug card except if a member utilizes prescription medications impacted by the UM programs defined below. All OK members will get new ID cards. IL members with drug cards will not get new ID cards. No NM or T members will receive new ID cards. Rx UM FAQs October 26, 2011 Page 2
4. What is Prior Authorization and when does it apply? Before the member can receive coverage for some medications, their doctor will need to obtain prior approval from Blue Cross and Blue Shield of (IL/OK/NM/T) and/or certain criteria must be met. Some examples of medications that may require prior authorization are those used to treat rheumatoid arthritis, hepatitis C, hypertension, asthma and epilepsy. For a complete listing of medications they can call the number on the back of their ID card (call the Prescription Drug Program number where available) or visit the website at: IL http://www.bcbsil.com/member/rx_drugs.html 5. What is Step Therapy and how does it affect the member/the medications the member currently takes? Step Therapy takes a step approach to providing coverage for the drugs that treat the member s condition. This means that the member may first need to try more clinically appropriate or cost effective drugs before other drugs are approved by their health plan. For existing members, if they are currently taking a drug named in a step therapy program, and if it is working for them, they can continue receiving the drug because we don't want to interrupt their current drug therapy. However, if they get a new script for a drug they haven't taken in the past and it's in one of the step therapy categories, they will be required to follow the step therapy requirements. For new members who have been on a drug in one of the step therapy categories, when they go to the pharmacy to get their medication filled and use their new ID card, their claim will reject if it's for the formulary brand or non-formulary brand. They will either need to switch to the generic for that particular brand or get a new script for another generic in the class if there are no generic products for the particular brand. If they want to try one of the other generics in the class, they will need a new script from their doctor. If their doctor wants them to stay on the brand product, the doctor will need to complete the prior authorization form and submit it for review/approval. For a complete list of medications that require this approach, they will need to call the number on the back of their ID card (call the Prescription Drug Program number where available) or visit the website at: IL http://www.bcbsil.com/member/rx_drugs.html Rx UM FAQs October 26, 2011 Page 3
6. What are the new Quantity Limits for medications? Quantity limits or Dispensing limits refers to certain medications that have a specific amount of covered medication per prescription or in a given time period. These limits are based on approved dosage regimens from the U.S. Food and Drug Administration and generally accepted pharmaceutical and manufacturer s guidelines. For a complete listing of medications having these limits, the member can call the number on the back of their ID card (call the Prescription Drug Program number where available) or visit the website at: IL http://www.bcbsil.com/member/rx_drugs.html 7. What are Specialty Medications and what is the Specialty Pharmacy Program? Specialty medications are drugs used to treat complex medical conditions and are often injected or infused. To be eligible for this benefit, members in OK, NM and T must get them through the preferred Specialty Pharmacy Provider, Triessent. IL members will receive a lesser benefit (50% coverage) if they choose not to use Triessent. To get a complete listing of these medications and procedures to follow, the member may contact Prime Therapeutics at the Prescription Drug Program number on the back of their ID card. Texas members can call the customer service number on their card and follow prompts for the Prescription Drug Program. 8. What are the new rules regarding Home Delivery (Mail Order) for Prescription Maintenance Drugs? OK/NM/T: Maintenance drugs are those a member may take on a regular basis for conditions such as high cholesterol, high blood pressure or asthma. Once they have received two fills of covered medications at their retail pharmacy they are required to obtain future fills through the Home Delivery Program. NOTE: This program is not applicable in IL. 9. I have never used Home Delivery (Mail Order). How do I obtain information about this program? OK/NM/T: The member can call Prime Therapeutics at the number on the back of their ID. Texas members can call the customer service number on their card and follow prompts for the Prescription Drug Program. (Note: program does not apply to IL members.) They may also visit the website at: 10. What is Member Pay the Difference? If a member requests a brand name drug for which a generic equivalent is available, they will pay the coinsurance, based on their benefit, plus the difference between the brand drug and its generic equivalent. Rx UM FAQs October 26, 2011 Page 4
11. Is there a transition plan or are there exceptions to any of these UM programs for existing members? Member Pay the Difference - Members will be required to follow the Member Pay the Difference guidelines no matter if they are on a drug currently or not starting 1/1/12. Mandatory Mail - Starting 1/1/12, existing members using a drug will get 2 grace fills (just like new members), then will have to go through mail for any benefits (OK, NM) and to get maximum benefits in IL. Specialty Pharmacy - No grandfathering. Therefore, members will have to utilize the preferred Specialty Pharmacy Provider beginning 1/1/12. Step Therapy - The existing member can continue using the prescribed step drug(s). However, if they get a new script for a drug they haven't taken in the past and it's in one of the step therapy categories, they will be required to follow the step therapy requirements beginning 1/1/12. Prior-authorization - No grandfathering. Beginning 1/1/12, members taking a drug on the prior authorization list will have to go through the prior authorization process. The physician will have to complete the appropriate form and submit it for approval. 12. What is Out-of-Pocket (OP) Expense Limit? (for OK members only changing from Stop Loss to OP) OP is the maximum amount a member would be required to pay in a year. For HealthCheck Basic, HealthCheck Select and Personal Blue plans this maximum does not include any deductible or copayment the member is required to pay, but it does include any coinsurance payments. For HealthCheck HSA coinsurance and deductible is included in the OP. 13. How am I impacted by the change from Stop Loss Limit to Out-of-Pocket Expense Limit? For Oklahoma HealthCheck Basic and Select and Personal Blue plans only, the stop loss limit has been converted for non-grandfathered members to Stop Loss. The New OP amounts for the Oklahoma HealthCheck Select and Basic plans and Personal Blue Plans are below: Oklahoma switch to OP from Stop Loss Products HealthCheck Select HealthCheck Basic Personal Blue Plan Current Annual Stop Loss Amounts $5,000 BlueChoice PPO network $10,000 BlueTraditional providers $10,000 Medical Stop Loss $20,000 Rx Stop Loss $10,000 The BlueChoice Network $20,000 Out of Network New Annual OP Amounts Blue Choice PPO Network: $1,000 per member Blue Traditional & Out-of-Network: $3,000 per member Medical: $2,500 per member Drug: $10,000 per member $2,250 BlueChoice (in-network) per member $6,000 Out of Network per member Rx UM FAQs October 26, 2011 Page 5
Important Phone Numbers Illinois Oklahoma New Mexico Texas Customer Service Prescription Drug Program 1-800-538-8833 1-866-520-2507 1-866-236-1702 1-888-697-0683 1-888-410-8823 1-877-353-0992 1-888-410-8823 1-888-697-0683 (follow the prompts) Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas, Divisions of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Rx UM FAQs October 26, 2011 Page 6