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Drug Formularies

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    What is a drug formulary?

    A formulary is a list of preferred generic and brand-name medications approved by the Food and Drug Administration (FDA) that are covered under your Blue Shield prescription drug benefit. You can check your Evidence of Coverage (EOC) or Certificate of Insurance (COI), or call the member services number on your Blue Shield member ID card, to determine whether the formulary applies to your plan. The fact that a drug is listed in the formulary does not guarantee it will be prescribed by your physician.
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    How are the Blue Shield drug formularies developed?

    The Blue Shield drug formularies are developed and updated quarterly by the Blue Shield Pharmacy and Therapeutics (P&T) Committee. The P&T Committee reviews medical literature concerning safety, effectiveness, and current use in therapy to determine which drugs should be included on our formularies. The medical information reviewed is from a variety of nationally recognized sources such as Medline, other databases, pharmaceutical manufacturers, medical professional associations, and peer-reviewed journals. The P&T Committee reviews and updates the formularies regularly to ensure they continue to provide coverage for drugs that are cost effective and safe. Through the use of the drug formulary associated with your plan, we can help maximize treatment quality while keeping your prescription drug costs lower.

    Additions or removal of drugs from the Blue Shield formularies that were approved by the P&T Committee are promptly listed on the online drug formulary page. For a copy of the drug formulary that applies to your plan and the latest formulary updates, please check either the Drug Formularies, or the Announcements section in the Pharmacy section of blueshieldca.com.

    If a drug is removed from your formulary, members who were already receiving the drug will continue to have the medication covered for as long as the treating physician continues to prescribe the drug, provided the drug is being prescribed appropriately and is considered safe and effective for treating the member’s medical condition.

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    What is a brand name drug?

    A brand-name drug is a medication that has been approved by the FDA for sale and marketing in the U.S., and has patent protection that limits which manufacturer(s) can make and sell the medication. Generic versions of brand drugs cannot be made or sold until the patent has expired. Once the patent has expired, generic versions of the medication can be sold alongside the brand version.
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    What is a generic drug?

    A generic drug has the same active ingredient and dosage form (e.g. tablet or capsule), and works in exactly the same way as its brand-name counterpart. When the patent on a brand-name drug expires, other drug manufacturers can apply to the FDA to make a generic version of the drug. The FDA approves generic drugs when manufacturers have proven that the generic version is equally safe and effective as the brand-name counterpart.

    Generic drugs usually cost less than the brand-name equivalent. Therefore, using generic drugs instead of a brand-name drug is one of the easiest ways to reduce your prescription costs. Most Blue Shield health plans provide a lower copayment for generic drugs, compared with brand-name drugs. Most generic drugs are covered even if they are not listed in your drug formulary.

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    What are specialty drugs?

    Specialty drugs are those drugs used to treat complex or chronic conditions, and which usually require close monitoring, such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancer, and other conditions that are difficult to treat with traditional therapies. Specialty drugs may be self-administered in the home by injection (under the skin or into a muscle), by inhalation, by mouth, or on the skin. These drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability.

    Specialty drugs are obtained from a Blue Shield specialty pharmacy, and may require prior authorization for medical necessity by Blue Shield.  If coverage is approved, the drug can only be obtained through one of our specialty pharmacies.

    You can download list of specialty drugs by going to the Drug Formularies in the Pharmacy section of www.blueshieldca.com and selecting your plan type (Medicare Part D, Individual and Family Plan, Small Group or Large Group).

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    What is prior authorization?

    Drug prior authorization is a process to obtain advanced approval of coverage for a prescription medication. Most medications are covered by Blue Shield without requiring prior authorization. However, some select drugs require your doctor to provide information about your prescription to determine coverage. Your doctor may provide information for a prior authorization review by calling or faxing a form to Blue Shield Pharmacy Services. Your doctor will be notified whether or not your prescription is approved for coverage.

    Prior authorization coverage requirements are determined by the Blue Shield P&T Committee to ensure that medications are prescribed for medically necessary reasons, used safely as recommended by the FDA and in medical studies, and used when formulary alternatives have been considered first. Drugs require prior authorization when:

    • Other drugs are recommended as first-choice treatment, based on nationally recognized clinical guidelines, the FDA, or the medical literature.
    • There is no significant clinical advantage compared with other formulary drugs that treat the same condition, based on clinical study results.
    • The drug should be reserved for rare or uncommon conditions.
    • The drug has a high potential for toxicity, abuse, or misuse.
    • The dose, prescription quantity, or duration of use exceeds that recommended by the FDA.

    Finally, prior authorization helps keep prescription costs affordable by suggesting use of formulary drugs first.

    Here are other situations when prior authorization may be necessary to request an exception to the coverage status of a prescription:

    • Non-formulary drugs for members with a closed formulary plan (check your Evidence of Coverage or Certificate of Insurance/Policy to see if your plan is a closed formulary plan, or call the customer service number on your member ID card).
    • Prescriptions that exceed the maximum limits described in the drug formulary.

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    What is step therapy?

    Step therapy is the practice of beginning drug therapy for a medical condition with drugs considered first-line for safety and cost-effectiveness, then progressing to other drugs that may have more side effects or risks or that are more costly. The P&T Committee may determine that coverage of selected drugs requires step therapy with first-line drugs before covering the prescribed medication. Step therapy requirements are based on how the FDA recommends that a drug should be used, nationally recognized treatment guidelines, medical studies, information from the drug manufacturer, and the relative cost of treatment for a condition.  Other common terms used for step therapy are:  “prerequisite therapy,” “prior therapy,” or “step therapy protocol.”

    If step therapy coverage requirements are not met for a prescription and your doctor feels that the medication is medically necessary for you, your doctor may request an exception to the coverage requirements by requesting a prior authorization review by contacting Blue Shield Pharmacy Services by phone or fax.

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    How does the formulary work with my prescription drug benefit?

    Blue Shield offers these types of outpatient prescription drug benefits

    • A closed formulary plan provides coverage for generic drugs, formulary brand-name drugs, and specialty drugs. Non-formulary drugs and most specialty drugs are covered only when prior authorization is approved. 
    • An incentive formulary plan provides coverage for generic drugs, formulary brand-name drugs, and specialty drugs. Non-formulary drugs are also covered for a higher copayment. Prior authorization approval may be required to cover some specialty drugs and certain non-formulary drugs. If coverage for a non-formulary drug requiring prior authorization is approved, you are responsible for the non-formulary copayment.
    • Some plans underwritten by Blue Shield of California Life & Health Insurance Company do not cover brand-name drugs. You may want to check your Certificate of Insurance (COI)/Policy, or call the customer service number on your Blue Shield member ID card, to determine whether you have brand-name drug coverage.

    Copayments for generic drugs are always lower than the copayments for formulary brand name, non-formulary, and specialty drugs. For most plans, if you select a brand-name drug when a generic equivalent is available, you pay the difference between Blue Shield’s cost for the brand-name drug and its equivalent generic drug, in addition to your generic copayment.

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    How do I use the Blue Shield Drug Formulary?

    To ensure that the medication your doctor prescribes is covered, and to minimize your out-of-pocket expenses, we recommend that you and your doctor consult the Blue Shield Drug Formulary related to your plan before writing or filling prescriptions. It may be helpful to bring your Blue Shield Drug Formulary when you visit your doctor, so that you and your doctor can make decisions about alternative medications, if necessary. Ask your doctor to prescribe a generic drug when you need to be treated with medication. If a generic drug is not available, or if your doctor prescribes a brand-name drug that is not listed in the formulary, consider asking your doctor whether a formulary brand-name drug may be just as effective and right for you.

    Always check the Drug Formularies in the Pharmacy section of www.blueshieldca.com for the most current information about which drugs are on your formulary.

    The Blue Shield Drug Formularies include most generic drugs (unless otherwise excluded), even if they are not listed. Some generic drugs are in classes that are excluded from coverage, such as a drug used for cosmetic purposes.  Please refer to your Blue Shield Summary of Benefits and your Evidence of Coverage (EOC) or Certificate of Insurance (COI)/Policy for benefit exclusions.

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    How can I obtain a copy of my plan's Blue Shield Drug Formulary?

    You can view the most up-to-date drug formularies online.  Please check the Drug Formularies in the Pharmacy section of www.blueshieldca.com for the most current information about which drugs are on your plan's formulary. You can also obtain a printed copy by calling Member Services. The number is listed on your Blue Shield ID card.
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    Is my coverage information available to my doctor for electronic prescriptions (e-prescriptions)?

    Yes, your doctor can obtain information about your prescription benefit, including copays, what’s covered on your drug formulary, and what other prescription medications you have filled at a pharmacy in the Blue Shield network.  By using e-prescription technology, your doctor can view information about potential drug interactions and side effects before prescribing new medications for you at the time of your visit.  Your doctor can also choose medications that are covered on your prescription benefit and see what drugs are available as a low cost generic before going to the pharmacy.

    When your doctor uses e-prescription technology, once a prescription has expired, the pharmacy can automatically notify your doctor to renew it electronically, saving time and making it easier for you and your doctor.

    Ask your doctor to transmit your prescriptions electronically to the pharmacy on your next visit to experience the benefits of e-prescriptions.

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