Your Multi-tiered Prescription Drug Benefit Program bcnepa.com
What you need to know about your multi-tiered prescription drug program A formulary is our list of covered drugs and supplies organized by copay tiers, which defines how much they cost. The multi-tiered program helps keep your prescription drugs affordable because it uses a preferred formulary or drug list. A formulary is our list of covered drugs and supplies organized by copay tiers, which defines how much they cost. Preferred drugs are generally covered at a lower copay tier, which means they cost you less. Non-preferred drugs are generally covered at a higher copay tier, which means they cost you more. The formulary also shows you which drugs need prior approval. Our formulary is put together based on clinical review and feedback from health care providers. Your multi-tiered program covers* the prescription drugs and injectables (that you can give yourself) that are listed on the formulary. You are also covered for formulary insulin, glucose test strips, lancets, insulin syringes, metered-dose inhaler spacer devices and peak air flow meters. Each retail prescription drug you get at a pharmacy or drugstore is limited to a 30-day supply. Each maintenance prescription drug you get by mail through home delivery is limited to up to a 90-day supply. Each specialty prescription drug you get by mail through a specialty or limited distribution pharmacy is limited to a 30-day supply. * Please see your Policy to be sure that your coverage includes prescription drug benefits. If you get prescription drugs and they are not covered under your Policy, you will have to pay for all charges owed. Call the Express Scripts Customer Service Call Center at 1.877.603.8399, anytime, for more information on your specific prescription drug coverage. bcnepa.com
The multi-tiered prescription drug program works like this: Here is a chart showing an example of the cost per prescription with a $0/$10/$20/$35 copay program. Your actual copays (and annual deductible, if applicable) may be different, based on your specific benefit plan. Tier Level Tier 0* Tier 1 Tier 2 Tier 3 30-Day Supply $0 $10 $20 $35 90-Day Supply from an in-network, mail-order pharmacy What Is Covered $0 $20 $40 $105 Some generic drugs Most generic and some brand-name drugs Brand-name and some generic drugs that Blue Cross considers preferred in each medicine class. If you are taking a medicine on the tier 2 list, your doctor may work with you to select a tier 0 or tier 1 medicine to meet your needs. Brand-name and some generic drugs that Blue Cross considers non-preferred in each medicine class. If you are taking a medicine on the tier 3 list, your doctor may be able to work with you to select a tier 0, tier 1 or tier 2 preferred medicine to meet your needs. *The $0 copay, as well as the other copays, applies only after you meet your annual deductible, if applicable. If you or your doctor selects brand-name drugs when generics are available, you will have to buy up this means you must pay the extra cost for the difference between the brand name and the generic, plus your copay and/or deductible, if applicable. How do I use my coverage? A sample PPO ID card First, check the formulary to make sure you don t need prior approval (authorization) for your prescription. If you do, make sure your doctor gets approval. Then, ask if your pharmacy is in the Express Scripts network. Prescription drugs are covered only when you get them from in-network pharmacies Next, show your ID card at your in-network pharmacy ID number Rx Information JOSEPH DOE QFG123456789001 Plan Code Rx ID Rx Group Rx PCN Rx BIN 274 123456789001 BLPA01 A4 012345 Plan BLUECARE PPO PRIMARY COPAY SPECIALTY COPAY $20 $40 Then, pay the applicable copay for each prescription PPO Some multi-tiered programs include a deductible. This means that, until your deductible is met, you are responsible for paying the pharmacy the full cost for the drug. However, your cost will be Blue Cross of Northeastern Pennsylvania s discounted amount. After you and any covered family members meet your deductible, you will then have to pay only the multi-tiered copay. See the enclosed list of covered benefits for the specific deductible and/or copay amounts you must pay with your plan. See your handbook for covered services. This card does not guarantee eligibility for benefits. Providers: All claims must be filed with your local Blue Cross or Blue Shield Licensee. Visit www.bcnepa.com for online services and health-related information. Service Representatives: 1-888-338-2211 (TTY): 1-866-280-0486 Out-of-Area Care: 1-800-810-BLUE (2583) Pharmacy Benefits: 1-877-603-8399 24/7 Nurse Now: 1-866-442-BLUE (2583) Providers: BlueCard Eligibility: 1-800-676-BLUE (2583) Precertification: 1-866-262-5623 Mental Health/Chemical Recovery: 1-800-577-3742 Pharmacists Call: 1-877-243-2507 First Priority Life 19 North Main St. Wilkes-Barre, PA 18711 Pharmacy Benefits Administrator Rx phone number Prescription Drug Benefit Program 1
How can I save money on prescription drugs? Check the formulary or ask your doctor what tier your drug is in Blue Cross of Northeastern Pennsylvania s drug formulary is made up of tiers. The tier level will tell you how much your copay is. You can save money by using the lowest tier drug possible. If you re prescribed a tier 3 drug (a higher copay), you can ask your doctor to prescribe a tier 0, tier 1 or tier 2 drug when possible. Please know that if you leave the pharmacy with the drug, the pharmacy, by law, will not let you return the medicine. The tiers work like this Tier level Tier 0* Tier 1 Tier 2 Tier 3 Your copay amount No copay (free) Lowest copay Medium copay Highest copay * The $0 copay, as well as the other copays, applies only after you meet your annual deductible, if applicable. Blue Cross of Northeastern Pennsylvania uses one of 2 prescription drug formularies, depending on your health insurance plan: the multi-tiered formulary or the Health Care Reform formulary. The drug formularies may change at any time. Call the Express Scripts Customer Service Call Center, 24/7, at 1.877.603.8399, or visit bcnepa.com/pharmacy.aspx and click on Prescription Drug Formularies to see the most current formularies. If you are not sure which formulary applies to your health insurance plan, please call Customer Service at the number on the back of your member ID card. If you don t have an ID card yet, check with your employer er or group benefits administrator. Or, if you are not a member yet, but are shopping for an individual plan, call 1.866.514.2454 to learn more. 2 bcnepa.com
Here s an example of how you can save money by using lower-tier drugs Jenny has high blood pressure. She currently takes Benicar and pays a $35 copay each month. That s $420 a year. The tier 0 generic, lisinopril, is a different drug also used to treat high blood pressure, but it costs only $0 a month. Jenny saves $420 a year! Why pay more? $0 $100 $200 $300 $400 $500 Tier 3 $35 copay per month totaling $420 a year Tier 2 $20 copay per month totaling $240 a year Tier 1 $10 copay per month totaling $120 a year This example is for illustrative purposes only. It does not reflect an actual situation or payment involving a Blue Cross member. Drug prices were adjusted for this example and may not reflect actual costs. Tier 0* $0 copay per month totaling $0 a year *The $0 copay, as well as the other copays, applies only after you meet your annual deductible, if applicable. Make sure you get prior approval (authorization) if you need it Check the formulary to see if you need prior approval before you go to the pharmacy. This means you need approval for certain drugs to be covered when there may be a more cost-effective treatment option available. Drugs that need prior approval are identified in the formulary by PA. Make sure your doctor gets approval, if needed, so the drug is covered. Certain medications are limited to the quantities that are listed in the formulary. You need prior approval for coverage of quantities that are larger than those generally recognized as medically necessary. Here s how the process works Your doctor needs to complete and submit an Rx Prior Authorization form to Blue Cross of Northeastern Pennsylvania by fax or electronically. Your doctor can get the form from the Express Scripts Customer Service Call Center or online at bcnepa.com/pharmacy.aspx under Pharmacy Related Forms. Your doctor s request will be reviewed by a Blue Cross of Northeastern Pennsylvania pharmacist, who will make a decision based on medical necessity. If your prescription has been approved, the drug will be covered, and we will let you know in writing. If your prescription is not approved, you may still choose to buy it, but you will have to pay for it in full. For BlueCare HMO plans, all decisions to deny coverage will be reviewed by a medical director. If coverage is denied, you will be notified and given the choice to appeal the decision. If you do not get approval before buying the prescription drug, no matter what our decision, you will have to pay for it in full. Prescription Drug Benefit Program 3
How else can I save money? In addition to using the lowest tier drugs to save on your copay, there are other things you can do to save money. For example, ask your doctor to prescribe generic drugs when possible. Also, follow step therapy guidelines and use in-network pharmacies, including specialty pharmacies. Use generics. Generic drugs are drugs that cost less but provide the same amount of the active ingredient in the same time frame as the brand-name version. And they re just as safe. Your doctor can help you save money by prescribing generic drugs when possible. To get a brand-name drug when a generic equivalent is available, you or your doctor must request it from your pharmacy. If you or your doctor selects brand-name drugs when generics are available, you will have to buy up i.e., pay a higher cost. That means you have to pay the difference in cost between the brand name and the generic, plus your copay and/or deductible, if applicable. Here s an example of how much more you would have to pay for a brand name when a generic is available: Rosa gets migraine headaches, and takes a brand-name drug, with a retail cost of $300/month. Instead, she might consider the generic drug, with a retail cost of only $70/month. Pharmacy receipt Monthly cost Brand-name drug Rosa pays a copay for a Meet Rosa Follow step therapy guidelines. Check the formulary to see if your prescription drug needs step therapy. Step therapy means you are covered for one or more medically appropriate first-step medicines before you will be covered for a second-step medicine. Medications that require step therapy are identified in the formulary by ST. Your doctor will need to request prior approval to use a second-step medication without using the required firststep medication. If approval is denied, you can pay the full cost of the drug or file an appeal. However, many less-costly drugs and generics are just as effective as drugs that cost much more. Use in-network pharmacies. Prescription drugs are covered only when you get them from in-network pharmacies. In-network pharmacies are those that are part of the Express Scripts National Pharmacy Network. To find an in-network pharmacy (as well as specialty pharmacies), call the Express Scripts Customer Service Call Center, toll-free, at 1.877.603.8399, anytime, or go online at bcnepa.com/pharmacy.aspx and click on Find a Pharmacy. Use specialty pharmacies for specialty drugs. Specialty drugs are high-cost drugs used to treat serious or chronic conditions. These drugs typically need special handling or refrigeration. Certain specialty drugs are available only at specialty pharmacies and are identified in our formulary by SP. You can find a list of in-network specialty pharmacies online at bcnepa.com/pharmacy.aspx under Specialty Drugs and Pharmacies. You can also call the Express Scripts Customer Service Call Center at 1.877.603.8399, anytime. brand-name drug $30 Plus, she pays the buy-up fee (see box below) +$230 Rosa s total cost for the brand-name drug each month $260 Buy-up fee: Brand-name drug retail cost $300 Generic drug retail cost $70 The buy-up fee is the difference in cost between the brand-name and the generic drugs $230 By choosing the brand-name drug, Rosa has to buy up. That means she has to pay her copay PLUS the difference in retail cost between the brand name and the generic. If Rosa chooses the generic, her cost is only her copay, saving her at least $250 a month! Rosa saves $250 per month by using the generic drug Pharmacy receipt Monthly cost Generic drug Rosa s cost for the generic drug (copay only) $10 Rosa s cost for the brand-name drug (copay and buy-up fee) $260 Comparison Rosa s cost for the generic drug (copay only) $10 What Rosa saves per month by using a generic drug $250 4 bcnepa.com This example is for illustrative purposes only. It does not reflect an actual situation or payment involving a Blue Cross member. Drug prices were adjusted for this example and may not reflect actual costs.
Use home delivery for maintenance meds Maintenance medications are those that you take long term, usually for a condition like high blood pressure or high cholesterol. Use home delivery for most maintenance prescription drugs and have up to a 90-day supply sent to your home. The multi-tiered program includes Select Home Delivery, which requires you to make an active decision about where you fill your medications through home delivery or at a local retail pharmacy. You can start home delivery with your initial prescription or you may get your 1st and 2nd fills of your maintenance medication at any in-network retail pharmacy. You must contact Express Scripts at 1.866.307.9623 or at StartHomeDelivery.com with your decision before your 3rd fill at the retail pharmacy. With home delivery, you can feel secure knowing that registered pharmacists carefully check each prescription so you ll get the attentive service you deserve. You can also feel comfortable knowing that millions of prescriptions are sent safely through the mail every year. How does home delivery work? First, check the enclosed list of covered benefits for your specific home delivery copay amount Then, call your doctor to get a written prescription for your maintenance medications for up to a 90-day supply The home delivery copay applies no matter what amount you order. It is your responsibility to ask that your doctor specify a 90-day supply on your prescription to get the greatest benefit from this program Make sure you don t need prior approval; if so, get the approval before sending the prescription to the home delivery pharmacy Finally, fill out the home delivery form on page 7 and send it with your prescription and payment to the address listed on the form Or, ask your doctor s office to fax the home delivery form to Express Scripts for the quickest possible service. This form must include your member ID number, found on your ID card, to process your order Once you ve sent your prescriptions to Express Scripts, allow up to 14 days for your medications to arrive. You ll get a phone call telling you when your order has shipped and when you can expect delivery. You can also track your order online at express-scripts.com If there are prescriptions that you need right away, you should have them filled by your local retail pharmacy. Because the law calls for pharmacies to have the original prescription on file, you will need to get a new written prescription from your doctor to use the Express Scripts Home Delivery program. Prescriptions you may have on file with any other home delivery service will not transfer to Express Scripts. How to order refills with home delivery By following the simple steps above, you order your medicines and they re delivered right to your home. And refills are just as easy. A reorder envelope and refill notice will be sent with all prescriptions. It will tell you the number of refills left on your prescription, if any. To order your refill, simply send your refill order no later than the date marked on the notice, or call 1.877.603.8399. For the quickest service possible, order your refills online. Just visit bcnepa.com/pharmacy.aspx to use the Express Scripts Self-Service site. If you do not have refills left, you must ask your doctor for a new prescription. Prescription Drug Benefit Program 5
Use Self-Service to manage your benefits Express Scripts Self-Service can help manage your prescription drug benefits In addition to ordering refills, Self-Service allows you to have personalized prescription drug benefit information at your fingertips. Sign up for Express Scripts Self-Service through bcnepa.com/pharmacy.aspx. All you need is your Rx ID number, found on the front of your member ID card. The site can give you: Personalized benefit and claims information Home delivery pharmacy registration and refill information A Message Center to email service reps A list of your plan s preferred drugs (drug formulary) Drug, health and wellness information A list of in-network pharmacies across the country On the go? Try Express Scripts mobile app You re just a click away from staying on track with your meds through the Express Scripts mobile app. View orders, check drug interactions or even find the closest retail pharmacy in seconds, so you can keep track, keep on schedule and keep feeling good. Get the app now for your mobile device by searching for Express Scripts in your app store and download it for free today. What if I need a refill while I m traveling? If you re planning to travel outside of the service area, you can refill your medication before you leave. Ask your pharmacist to call Express Scripts to make this request any time before the next regular refill date. However, if you re out of the area and realize you need a prescription filled, Express Scripts has pharmacies throughout the U.S. These out-of-area, in-network pharmacies can give the same services as your local in-network pharmacy. To find an out-of-area, in-network pharmacy, call the Express Scripts Customer Service Call Center at 1.877.603.8399 anytime, or go online at bcnepa.com/pharmacy.aspx and click on Find a Pharmacy. What if I use a pharmacy out of the network? You do not have coverage for prescription drugs at pharmacies out of the network. There is also no coverage for prescription drug claims that were not submitted electronically from an in-network pharmacy, except in special circumstances and when approved by Blue Cross of Northeastern Pennsylvania. In special circumstances, if you buy a prescription drug from a pharmacy that was not able to send your claim electronically, you will need a Prescription Drug Reimbursement form. Call the Express Scripts Customer Service Call Center to get the form or go online at bcnepa.com/pharmacy.aspx under Pharmacy Related Forms to print it. Then send the paid-in-full receipt and reimbursement form to our Pharmacy Management department at Blue Cross of Northeastern Pennsylvania, 19 North Main Street, Wilkes-Barre, PA 18711-0302. After we review the claim, Blue Cross of Northeastern Pennsylvania may reimburse you, up to the price we would have paid if the claim had been sent in electronically by an in-network pharmacy, less your copay and deductible, if applicable. However, we cannot guarantee reimbursement. 6 bcnepa.com
Please fill out all parts of the form. Mail the form, your prescription and payment to: Express Scripts, Inc., P.O. Box 66566, St. Louis, MO 63166-6566. Prescription Drug Benefit Program 7
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What is not covered? Injectable drugs used to treat infertility Drugs that do not require a prescription, unless specifically included in your Policy or unless your plan covers the drugs under Essential Health Benefits as required by Health Care Reform Medical supplies, devices, equipment and test agents, except for those formulary products used in the treatment of diabetes and for peak flow meters Drugs used for cosmetic purposes and for weight loss Drugs that are not FDA approved and drugs determined to be experimental and/or investigational by the FDA Multiple vitamins, except those used for pregnancy and multiple vitamins with fluoride for the prevention of tooth decay in children under age 16 Higher charge for a brand-name drug for which there is a generic equivalent drug available Drugs for impotence, in excess of 4 doses per month Drugs requiring prior authorization that have not been authorized as an exception Drugs that cannot be self-administered Allergy extracts for allergen immunotherapy Administration or injection of any drug Replacement of lost, stolen or damaged drugs Take-home drugs given by a hospital or a doctor Drugs that should not be dispensed, based on the pharmacist s professional judgment Prescription drug program Express Scripts Customer Service Call Center 24/7, 365 days a year 1.877.603.8399, (TTY) 1.800.899.2114 Express Scripts Self-Service bcnepa.com/pharmacy.aspx Customer Service If you have any questions about your health insurance plan, please call Customer Service at the appropriate number, weekdays, between 8 a.m. and 5 p.m. BlueCare Traditional, BlueCare Senior 1.800.829.8599, (TTY) 1.866.280.0486 BlueCare HMO, BlueCare HMO Plus 1.800.822.8753, (TTY) 1.800.413.1112 BlueCare PPO, BlueCare QHD PPO 1.888.338.2211, (TTY) 1.866.280.0486 BlueCare Custom PPO, BlueCare QHD Custom PPO, BlueCare EPO, AffordaBlue SM 1.888.345.2346, (TTY) 1.866.280.0486 All myblue Plans 1.888.728.3840, (TTY) 1.866.280.0486 You can email Customer Service through our Self-Service Message Center, anytime, at bcnepa.com. Prescription Drug Benefit Program 9
This brochure has general information about the prescription drug benefit program. It is not meant to be a substitute for the terms, provisions, limitations and conditions set by the contract/policy. A complete list of benefits and exclusions is included in the contract/policy between you or your employer and Blue Cross of Northeastern Pennsylvania/Highmark Blue Shield/First Priority Health and/or First Priority Life. Final interpretation of any provision is governed by the contract/policy. Blue Cross of Northeastern Pennsylvania provides prescription drug coverage with administrative assistance from Express Scripts, Inc., an independent pharmacy benefit management company not affiliated with the Blue Cross and Blue Shield Association. Self-funded group benefits may differ from the benefits and services described here. See your Summary Plan Description for complete details of your coverage. BlueCare HMO Plans: This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. 1.800.822.8753 Blue Cross of Northeastern Pennsylvania is a Qualified Health Plan issuer in the Federally Facilitated Marketplace. Blue Cross of Northeastern Pennsylvania administers health insurance plans for Blue Cross of Northeastern Pennsylvania, Highmark Blue Shield, First Priority Health and First Priority Life Insurance Company. 03-B053B-RX 2/15 Blue Cross of Northeastern Pennsylvania. 2015.