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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 cover only generics for several classes. All covered prescription drugs fall into tiers, which represent 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 certain Small Group* plans. This plan has 5 tiers.
  2. Essential Formulary Guide with Preventive Copays is for members who have High-Deductible Health Plans with the BlueCross Preventive Drug List. This plan has 6 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 Limit: 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 Guide

The Essential Formulary Guide applies to Individual and certain Small Group* plans.
*Please note that the Essential Formulary Guide (5 Tier) does not apply to the following Small Group plans:

  • BlueCross SG Bronze 19
  • BlueCross SG Bronze 20
  • BlueCross SG Silver 23
  • BlueCross SG Silver 25
  • BlueCross SG Silver 41
  • BlueCross SG Silver 52
  • BlueCross SG Gold 24
  • BlueCross SG Gold 25
  • BlueCross SG Gold 26

For the plans listed above, please refer to the 2017 Essential Formulary Guide with Preventive Copays.

2017 Essential Formulary Guide

2018 Essential Formulary Guide

What's Changing on the Essential Formulary Guide (5 Tier) for 2018?

What's a Drug Tier?
The formulary includes five tiers of medications. The copay, deductible or coinsurance for your prescription is based on which tier your drug falls into.

  • Tier 1 – Generic Drugs
  • Tier 2 – Preferred Brand Drugs
  • Tier 3 – Non-Preferred Brand Drugs
  • Tier 4 – Specialty Drugs
  • Tier 5 – Drugs with $0 Cost Share

Essential Formulary Guide with Preventive Copays

The Essential Formulary Guide with Preventive Copays 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 cover 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.
The Essential Formulary (6 Tier) is based on the use of preventive drugs. There are two Preventive Drug lists used. In this formulary, the out of pocket member costs is based on the drugs on the BlueCross Preventive Drug List or the drugs on the Affordable Care Act (ACA) $0 Copay Preventive List.

Essential Formulary Guide with Preventive Copays

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

  • BlueCross SG Bronze 19
  • BlueCross SG Bronze 20
  • BlueCross SG Silver 23
  • BlueCross SG Silver 25
  • BlueCross SG Silver 41
  • BlueCross SG Silver 52
  • BlueCross SG Gold 24
  • BlueCross SG Gold 25
  • BlueCross SG Gold 26

2017 Essential Formulary Guide with Preventive Copays

2018 Essential Formulary Guide with Preventive Copays

What's Changing on the Essential Formulary Guide (6 Tier) for 2018?

What's a Drug Tier
This formulary includes six tiers of medications. The copay, deductible or coinsurance for your prescription is based on which tier your drug falls into.

  • Tier 1 – Generic Drugs with copay-based on the BlueCross Preventive Drug List
  • Tier 2 – Preferred Brand Drugs with copay-based on BlueCross Preventive Drug List
  • Tier 3 – Non-Preferred Brand Drugs with copay-base on BlueCross Preventive Drug List
  • Tier 4 – Specialty Drugs with Deductible/Coinsurance
  • Tier 5 – Drugs with $0 Cost Share per Affordable Care Act (ACA) $0 Copay Preventive List
  • Tier 6 – Generic or Brand Non-Specialty Drugs with Deductible/Coinsurance
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