December 30, 2015

Effective January 1, 2016, Blue Cross and Blue Shield of North Carolina (BCBSNC) will make two key changes to their Pharmacy Program.

Pharmacy Tier Definition Change
BCBSNC will change the definitions of their pharmacy tiers. These changes will take effect January 1, 2016, for all group plans, regardless of the client’s renewal date.

As BCBSNC moves toward industry-standard definitions, specific references to generic, preferred and non-preferred, and select brand names have been removed. The new definitions will also give BCBSNC the flexibility to tier medications based on cost, rather than categories.

The new tier definitions are as follows:

Four-Tier Pharmacy Plans

four tier pharm

Five-Tier Pharmacy Plans

five tier pharm

BCBSNC members with January 1 effective dates will see these new tier definitions in their 2016 benefit booklets and online. BCBSNC will issue a changes page with the new definitions to alert members with effective dates other than January 1.

To make it easier for members to find specific information about their prescription medication benefits, BCBSNC will begin adding a letter to member ID cards, starting January 1, 2016. In the bottom right corner, there will be a large "Rx," followed by a letter. Members can enter this letter in our "Find a Drug" tool to see their correct formulary and pharmacy network.

Drug Tier Changes Effective January 1, 2016
Effective January 1, 2016, BCBSNC will change the tier status of some drugs on their prescription drug formularies. BCBSNC reviews its prescription drug formularies and makes tier status changes based on the availability of drugs (both brand name and generic) in the market. These changes help provide their members with access to drugs that are safe, effective and as cost-efficient as possible.

Members are being notified by BCBSNC about any specific drugs they currently take (prescription filled within the last four months) that will change tier status as of January 1, 2016.

Why are these tier changes being made?
From time to time, BCBSNC reviews its prescription medication formularies and may change the tier of certain medications. BCBSNC regularly reviews medical research and costs of medications. A team of doctors and pharmacists uses this information to make sure BCBSNC covers the most effective medicines while keeping costs more affordable for everyone.

What’s the difference between this change and the drug tier definition change outlined above?
These are two distinct initiatives. The drugs moving to different tiers effective January 1, 2016 are changes related to and permitted by the tier definitions in member’s benefit booklets effective through 2015. These periodic tier changes are due to changes in the cost of the drug and/or in the classification of the drug by the U.S. Food and Drug Administration (FDA) or nationally recognized drug databases (e.g., Medispan).

The change in benefit booklet tier definitions on January 1, 2016 that removes the definition of tiers as generic, brand or non-preferred is only a change to align BCBSNC drug tiers with industry standards.

In 2016, BCBSNC may move drugs from one tier to another under the new tier definitions. These movements will be positive for the member. For example, BCBSNC will be able to offer a brand name version of medications at a lower cost more quickly than we can today and to keep up with the rapid cost increases in some of the generic medications.

How will this change affect BCBSNC members?
Based on the change of tier status, members may see their out-of-pocket costs increase. This cost increase will vary depending on the member’s prescription drug plan. Members should check their benefit booklet for a description of out-of-pocket costs associated with each drug tier.

EMPLOYEE COMMUNICATION

Below is a simplified message you can use to communicate this change with your employees.

Effective January 1, 2016, Blue Cross and Blue Shield of North Carolina (BCBSNC) will make two key changes to their Pharmacy Program.

Pharmacy Tier Definition Change
BCBSNC will change the definitions of their pharmacy tiers. These changes will take effect January 1, 2016.

As BCBSNC moves toward industry-standard definitions, specific references to generic, preferred and non-preferred, and select brand names have been removed. The new definitions will also give BCBSNC the flexibility to tier medications based on cost, rather than categories.

The new tier definitions are as follows:

Four-Tier Pharmacy Plans

four tier pharm

Five-Tier Pharmacy Plans

five tier pharm

To make it easier for members to find specific information about their prescription medication benefits, BCBSNC will begin adding a letter to member ID cards, starting January 1, 2016. In the bottom right corner, there will be a large "Rx," followed by a letter. Members can enter this letter in our "Find a Drug" tool to see their correct formulary and pharmacy network.

Drug Tier Changes Effective January 1, 2016
Effective January 1, 2016, BCBSNC will change the tier status of some drugs on their prescription drug formularies. BCBSNC reviews its prescription drug formularies and makes tier status changes based on the availability of drugs (both brand name and generic) in the market.  These changes help provide their members with access to drugs that are safe, effective and as cost-efficient as possible.

Members are being notified by BCBSNC about any specific drugs they currently take (prescription filled within the last four months) that will change tier status as of January 1, 2016.

Why are these tier changes being made?
From time to time, BCBSNC reviews its prescription medication formularies and may change the tier of certain medications. BCBSNC regularly reviews medical research and costs of medications. A team of doctors and pharmacists uses this information to make sure BCBSNC covers the most effective medicines while keeping costs more affordable for everyone.

What’s the difference between this change and the drug tier definition change outlined above?
These are two distinct initiatives. The drugs moving to different tiers effective January 1, 2016 are changes related to and permitted by the tier definitions in member’s benefit booklets effective through 2015. These periodic tier changes are due to changes in the cost of the drug and/or in the classification of the drug by the U.S. Food and Drug Administration (FDA) or nationally recognized drug databases (e.g., Medispan).

The change in benefit booklet tier definitions on January 1, 2016 that removes the definition of tiers as generic, brand or non-preferred is only a change to align BCBSNC drug tiers with industry standards.

In 2016, BCBSNC may move drugs from one tier to another under the new tier definitions. These movements will be positive for the member. For example, BCBSNC will be able to offer a brand name version of medications at a lower cost more quickly than we can today and to keep up with the rapid cost increases in some of the generic medications.

How will this change affect you?
Based on the change of tier status, you may see your out-of-pocket costs increase. You should check your benefit booklet for a description of out-of-pocket costs associated with each drug tier.  If you have questions related to a current prescription you are taking or would like to determine the tier that a prescription falls under, please visit the Find a Drug page or call the Customer Service number noted on the back of your ID card.