Bluecare health plan

3-TIER MANAGED RX PROGRAM

Revised for July 1, 2011
Madison BOE Unaffiliated Active HMO FD 450
$10 CO-PAYMENT GENERIC DRUGS
$15 FORMULARY BRAND NAME DRUGS
$35 NON-FORMULARY BRAND NAME DRUGS
Unlimited Annual Maximum
Description of Benefits
Your co-payment
Tier 1: Generic drugs
The term “generic” refers to a prescription drug that is considered non- proprietary and is not protected by a trademark. It is required to meet the same bioequivalency test as the original brand name drug. Tier 1 co-payment applies. Tier 2: Formulary brand name
The term “formulary brand name” refers to a brand name prescription drug identified on the formulary by Anthem Blue Cross and Blue Shield as a prescription drug with a Tier 2 co-payment. Tier 3: Non-formulary brand
The term “non-formulary brand name” refers to a brand name name drugs
prescription drug not identified on the formulary by Anthem Blue Cross and Blue Shield. Tier 3 co-payment applies. Annual Maximum
 When you purchase a generic drug at a participating How to use the 3-Tier Managed Rx Program
pharmacy, you’ll only be responsible for a $10 co- The 3-Tier Managed Rx Program incorporates different levels of co-payments for three types of prescription drugs: generic, formulary brand name and non-formulary brand name, as  When a generic equivalent is available and you obtain the defined in the chart above. The formulary lists generics and brand name version, you will be responsible for the Tier 3
brand name drugs that have been selected for their quality, co-payment plus the difference in cost between the safety and cost-effectiveness. These formulary drugs have generic and brand name drug. This provision applies lower member co-pays than non-formulary drugs (but may not unless your provider obtains prior authorization. When have a lower overall cost in all instances). You minimize your prior authorization is obtained (at the discretion of co-payments when you use generic prescriptions and brand Anthem Blue Cross & Blue Shield), you will be name prescriptions listed on the formulary. You’ll still have responsible only for the Tier 3 co-payment.
coverage for non-formulary brand name drugs not on the Concurrent Drug Utilization Review
Concurrent Drug Utilization Review (C-DUR) works with the Talk to your provider about using generic drugs or brand name retail pharmacy’s standard guidelines to provide a second
drugs included on the formulary. You’ll have lower level of quality and safety checks. The process, which is
provided on-line as part of the electronic claims filing process, helps promote access to safe, appropriate, cost-effective You will be responsible for one co-payment when medications for members. C-DUR involves a series of rules or purchasing up to a 30-day supply of prescription drugs guidelines, which identify potential medication therapy issues and deliver a message to the pharmacy by computer, before the You’ll be responsible for two co-payments when medication is dispensed. The process alerts the pharmacist of purchasing up to a 90-day supply of maintenance drugs potential issues such as drug-to-drug interactions, refills requested too close together, incorrect dosing or drug Generic Substitution: Prescriptions may be filled with the
generic equivalent when available.
Step Therapy is another element of C-DUR that consists of
specific criteria and dispensed pursuant to a prescription specialized programs that review pharmacy claims submitted issued by a physician, subject to co-payment. for a member against his/her prescription profile and can be  Anthem Blue Cross and Blue Shield will not be liable for any used to assist in controlling utilization and promoting quality, injury, claim or judgment resulting from the dispensing of any cost-effective drug therapies for patients. All therapy drug covered by this plan. Anthem Blue Cross and Blue protocols developed by APM are reviewed and approved by Shield will not provide benefits for any drug prescribed or the P&T Committee. The current drugs affected by step dispensed in a manner contrary to normal medical practice. therapies are: Ambien CR, Arthorotec, Celebrex, Enbrel,  Anthem Blue Cross and Blue Shield reserves the right to Elidel, Lunesta, Monopril, Penlac, Prilosec, Prevacid, apply quantity limits to specified drugs as listed on the formulary. If a member requires a greater supply, the member’s provider can follow the prior authorization process. A step therapy is requiring drug X, Y, or Z prior to receiving drug A. Step therapy protocols are built in the claims Prescription Drug Eligibility
processing system to search the member's history for the Eligible prescription drug benefits are limited to injectable insulin required drugs. If the claim history does not indicate the and those drugs, biologicals, and compounded prescriptions that member has had drug X, Y, or Z; drug A will reject at the are required to be dispensed only according to a written prescription, and included in the United States Pharmacopoeia, National Formulary, or Accepted Dental Remedies and New The member, pharmacy or physician may contact Anthem Drugs, and which, by law, are required to bear the legend: Prescription Customer Service to clarify the claim rejection. “Caution—Federal Law prohibits dispensing without a prescription” or which are specifically approved by the Plan. An APM representative reviews the criteria with the caller.
Limits and Exclusions
The caller is advised if the request is approved or more Benefits are limited to no more than a 30-day supply for
covered drugs purchased at a retail pharmacy, and no more than a 90-day supply for covered drugs purchased by mail
If additional information is needed, the member, pharmacy, or order. All prescriptions are subject to the quantity limitations Anthem Prescription may contact the physician. The physician imposed by state and federal statutes. may supply the additional information via telephone or fax. This drug rider does not provide drugs dispensed by other An APM support Specialist reviews the additional information than a licensed, retail pharmacy or our mail-order service; and compares it to the step therapy protocol. The request will any drug not required for the treatment or prevention of be approved and authorization entered into the pharmacy claim illness or injury; vaccines or allergenic extracts; devices and processor if the information matches the step therapy protocol. appliances; needles and syringes that are not prescribed by a Criteria is not met if the information does not match the step provider for the administration of a covered drug; therapy protocol. The caller is informed of the status of the prescriptions dispensed in a hospital or skilled nursing facility; drugs for use in connection with drug addiction; over- the-counter or non-legend drugs; antibacterial soaps/detergents, shampoos, toothpastes/gels and Pharmacy Programs

Voluntary Mail-service Program
Members have access to Anthem Rx, the voluntary mail- Benefits for prescription birth control are covered for most service pharmacy program. Members can order up to a 100-
groups. However, such coverage is optional if your group is day supply of these maintenance medications and have them self-insured or a bona fide religious organization. Check with The $10 generic/$15 formulary brand name/$35 non- formulary brand name co-payment and unlimited annual maximum apply. When ordering up to a 90-day supply, two co-payments will apply, as follows: $20 generic/$30 formulary
brand name/$70 non-formulary brand.

National Pharmacy Network
Members also have access to Community Rx, a network of
more than 65,000 retail pharmacies throughout the country.
Members may call 1-800-962-8192 to locate a participating
pharmacy when traveling outside the state.
Points to Remember
 Anthem Blue Cross and Blue Shield will provide coverage for
prescription drugs dispensed by a pharmacy when prescription drugs are deemed medically necessary based on

Source: http://www.madison.k12.ct.us/uploaded/docs/HR/Benefits/Unaffiliated/Health/Blue_Care_Prescriptions.pdf