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Limited Formulary

Limited Formulary Reference Guide

The Limited Formulary Guide will help you understand and use your pharmacy benefits. It contains a list of medications and drug tiers to help you know what your plan covers – and how much you might owe out of pocket. Pharmacy benefit plans that use the Limited 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.  All covered prescription drugs fall into one of three categories or tiers. Each tier represents the level of cost you’ll pay for that particular drug.

The formulary is revised on a regular basis to reflect the availability of new prescription drugs and other changes in the market. The drugs in the formulary are selected by a panel of physicians and pharmacists and the list is revised on a regular basis to reflect the availability of new prescription drugs and other changes in the market.

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.

2017 Limited Formulary Reference Guide

What’s Changing on the Limited Formulary for 2017?

The drug list includes three tiers of medications: generic, preferred brand-name drugs and non-preferred brand-name drugs. There’s also a Specialty Drug tier. The copay, deductible or coinsurance for your prescription is based on which tier your drug falls into. The lower the tier, the lower your cost share will be.

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.

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