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Essential Formulary

The Essential Formulary Guide will help you understand and use your pharmacy benefits. It contains a list of medications your plan covers – and how much you might owe out of pocket. Pharmacy benefit plans that use the Essential Formulary focus on the safe and effective use of generic drugs. These plans do cover selected brand-name drugs for certain drug classes, but covers only generics for several classes, only generics are covered. All covered prescription drugs fall into one of five categories or tiers. Each tier represents the level of cost that you will pay for that particular drug. There are two Essential Formularies.

  1. The Essential Formulary Guide applies to Individual and Small Group* plans. This plan has 5 tiers.
  2. Essential Formulary with Preventive Copay is for members who have High-Deductible Health Plans with the Preventive Drug List. This plan has six tiers.

Coverage Requirements and Limitations
To make sure that prescription drugs are used in a safe and cost-effective manner, some drugs have additional requirements that must be met before the prescription can be filled.  Those drugs will have an abbreviation next to the drug name to let your doctor or pharmacist know there are additional requirements.

Abbreviation

Description

PA

Prior Authorization:  The plan requires your physician to obtain prior authorization for certain drugs based on medical criteria.  This means that your physician will need to get approval before you may fill your prescription.

QL

Quantity Limits: For certain drugs, the plan limits how many doses you can get. This applies to drugs that are often taken the wrong way or are often taken in greater quantities than prescribed. 

ST

Step Therapy:  In some cases, your plan requires you to first try certain drugs to treat your medical condition before covering another drug for that condition.

 

Essential Formulary Reference Guide

The Essential Formulary Guide applies to Individual and Small Group* plans.
*Does not apply to the following small group plans:

  • BlueCross SG Bronze 11
  • BlueCross SG Bronze 17 (2017 Plan)
  • BlueCross SG Silver 23
  • BlueCross SG Silver 25
  • BlueCross SG Silver 41 (2017 Plan)
  • BlueCross SG Silver 28
  • BlueCross SG Gold 24
  • BlueCross SG Gold 25
  • BlueCross SG Gold 26

2017 Essential Formulary Reference Guide

What’s Changing on the Essential Formulary for 2017?

For these plans, please refer to the 2016 Essential Formulary with Preventive Drug Copays.

What's a Drug Tier?
The drug list includes five tiers of medications: generic, preferred brand name drugs, non-preferred brand-name drugs, specialty drugs and drugs with $0.00 Cost Share. The copay, deductible or coinsurance for your prescription is based on which tier your drug falls into.

Tier 1 – Generic Drugs

Lower Cost $

Tier 1 includes generic drugs offer the lowest member copayment. The active ingredient in a generic drug is chemically identical to the active ingredient of the corresponding brand name drug.

Tier 2 – Preferred Brand Drugs

Mid-Range Cost $$

Tier 2 drugs are usually available at a slightly higher copay or coinsurance than generic drugs. These drugs are designated preferred brand because they’ve been proven to be safe, effective and priced favorably compared to other brand drugs that treat the same condition.

Tier 3 – Non-Preferred Brand Drugs

Higher Cost $$$

Tier 3 drugs have the highest copay or coinsurance. These drugs are listed as non-preferred because they haven’t been found to be any more cost effective than available generics, preferred brands or over-the-counter drugs.

Tier 4 – Specialty Drugs

Higher Cost $$$$

The Specialty Pharmacy Program includes high-cost medications for serious chronic diseases such as hepatitis C, multiple sclerosis, arthritis and hemophilia.

After your provider prescribes one of these medications, it should be ordered from one of BlueCross BlueShield of Tennessee's preferred specialty pharmacy vendors.

Tier 5 – Drugs with $0 Cost Share

No Cost

Tier 5 drugs require no copayment. These drugs are preventive drugs as defined per the Affordable Care Act (ACA).

Essential Formulary with Preventive Copay

The Essential Formulary Guide with Preventive Copay will help you understand and use your pharmacy benefits. It contains a list of medications your plan covers – and how much you might owe out of pocket. Pharmacy benefit plans that use the Essential Formulary focus on the safe and effective use of generic drugs. These plans cover selected brand-name drugs for certain drug classes, but covers only generics for several classes.  All covered prescriptions drugs fall into one of six categories or tiers. Each tier represents the level of cost that you will pay for that particular drug.
This formulary is based on the use of preventive drugs. There are two Preventive Drug lists used.  In this formulary, the deductible/coinsurance/copay is based on the drugs on the BlueCross Preventive Drug List or the copays in the Preventive Drug list mandated in the Affordable Care Act (ACA).

Coverage Requirements and Limitations
To make sure that prescription drugs are used in a safe and cost-effective manner, some drugs have additional requirements that must be met before the prescription can be filled.  Those drugs will have an abbreviation next to the drug name to let your doctor or pharmacist know there are additional requirements.

Abbreviation

Description

PA

Prior Authorization:  The plan requires your physician to obtain prior authorization for certain drugs based on medical criteria.  This means that your physician will need to get approval before you may fill your prescription.

QL

Quantity Limits:  For certain drugs, the plan limits how many doses you can get. This applies to drugs that are often taken the wrong way or are often taken in greater quantities than prescribed. 

ST

Step Therapy:  In some cases, your plan requires you to first try certain drugs to treat your medical condition before covering another drug for that condition.

 

Essential Formulary with Preventive Copay Reference Guide

The Essential Formulary Guide with Preventive Drug Copays applies only to the following Small Group plans:

  • BlueCross SG Bronze 11
  • BlueCross SG Bronze 17 (2017 Plan)
  • BlueCross SG Silver 23
  • BlueCross SG Silver 25
  • BlueCross SG Silver 41 (2017 Plan)
  • BlueCross SG Silver 28
  • BlueCross SG Gold 24
  • BlueCross SG Gold 25
  • BlueCross SG Gold 26

2017 Essential Formulary with Preventive Copay Reference Guide

What’s Changing on the Essential Formulary for 2017?

What's a Drug Tier
The drug list includes six tiers of medications: generic, preferred brand-name drugs and non-preferred brand-name drugs. The copay, deductible or coinsurance for your prescription is based on which tier your drug falls into. The lower the tier, the less you’ll pay out of pocket.

Tier 1 – Generic Drugs with copay-based on BlueCross High Deductible Health Plan (HDHP) Preventive List

Lower/Mid-Range Cost $/$$

Tier 1 includes all Generic or Brand Non-Specialty Drugs with deductible/coinsurance.

Tier 2 – Preferred Brand Drugs with copay – based on BlueCross High Deductible Health Plan (HDHP) Preventive List

No Cost

Tier 2 drugs are typically preventive drugs per Affordable Care Act (ACA) and usually available at no cost.

Tier 3 – Non-Preferred Brand Drugs with copay-based on BlueCross High Deductible Health Plan (HDHP) Preventive List

Low Cost $

Tier 3 drugs are Generic Drugs with copay. These drugs are typically preventive drugs on the BlueCross Preventive Drug List. On this tier, you just pay a copay for preventive care medications instead of having to meet your plan’s deductible for certain prescription drugs.

Tier 4 – Specialty Drugs with Deductible/Coinsurance

Mid-Range Cost $$

Tier 4 drugs are usually available at a slightly higher copay or coinsurance than generic drugs. These drugs are designated preferred brand because they’ve been proven to be safe, effective, and priced favorably priced compared to other brand drugs that treat the same condition.

Tier 5 – Drugs with $0 Cost Share per Affordable Care Act (ACA) $0 Copay Preventive List

Higher Cost $$$

Tier 5 drugs have the highest copay or coinsurance. These drugs are listed as non-preferred because they haven’t been found to be any more cost effective than available generics, preferred brands, or over-the-counter drugs.

Tier 6 – Generic or Brand Non-Specialty Drugs with Deductible Coinsurance

Higher Cost $$$$

The Specialty Pharmacy Program includes high-cost medications for chronic, serious diseases such as hepatitis C, multiple sclerosis, arthritis, hemophilia and other conditions.

After your provider prescribes one of these medications, it should be ordered from one of BlueCross BlueShield of Tennessee's preferred specialty pharmacy vendors.

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