Group Leader Bulletin Bulletin G3A08 Blue Cross and Blue
Blue Cross and Blue Shield of Minnesota is making formulary changes in two therapeutic drug classes in its
Shield of Minnesota
continuing strategy to drive health cost savings for groups and members while preserving member choice and
to deliver pharmacy
The formulary changes are centered on non-sedating
cost savings in two
antihistamines (NSAH) used to treat allergies and proton pump inhibitors (PPI) used to treat acid reflux and
categories —
stomach ulcers — among the most significant cost drivers for group and individual health care purchasers.
non-sedating
Starting July 1, 2008, Blue Cross will add over-the-counter
antihistamines (NSAHs) (OTC) versions of NSAHs and PPIs to the formulary
(preferred drug list). These OTC products are substantially
and proton pump
less expensive than the same drugs offered behind the pharmacy counter as prescription drugs. The addition of
inhibitors (PPIs) — by
OTC products to the formulary preserves great treatment options for consumers and also allows the movement
adding over-the-counter of select expensive brand-name drugs in these two
therapeutic classes to “non-covered” status. These changes
drugs to formulary
will allow customers and their employees to get a much greater value for their health care dollar.
and moving select
Groups no longer need to have an OTC drug benefit to participate in this program since the OTC products in the
brand-name drugs to
NSAH and PPI categories have been added to Blue Cross’ formulary. When a member uses one of the formulary
“non-covered” status
OTC products, the member will pay the benefit plan’s lowest copay amount. Members will need a prescription for these new OTC formulary products to be covered by their health plan.
Blue Cross and Blue Shield of Minnesota • P.O. Box 64560 • St. Paul, MN 55164-0560
Formulary profile Proton pump inhibitors OTC/Rx (generic) 7/1/08 status Generic substitutes Therapeutic alternatives Member implication
Zegerid (Omeprazole/Sodium Bicarb) Non-covered
Non-sedating antihistamines OTC/Rx (generic) 7/1/08 status Generic substitutes Therapeutic alternatives Member implication
Loratadine/Pseudoephedrine Member has access to both the
Loratadine/Pseudoephedrine Cetirizine/Pseudoephedrine
Loratadine/Pseudoephedrine generic equivalent and therapeutic
Loratadine/Pseudoephedrine alternatives (lowest cost tier)
Group Leader Bulletin Who does this impact?
Members on plans with closed formularies who already
These changes impact any group with Prime Therapeutics
have a formulary exception for a drug moving to non-
as their pharmacy benefit manager and that uses the
covered status will continue coverage for the exception
Blue Cross preferred drug list. This includes all fully
insured groups and their members and self-insured
Members may continue to work with their doctors
groups and their members who use Prime Therapeutics
through the medical review process if there are
documented medical reasons why a certain member
Fully insured and self-insured groups with Prime
can benefit only from a non-covered drug.
Therapeutics as the pharmacy benefit manager who also
Questions
offer an over-the-counter drug benefit will continue to
Members can call customer service using the phone
realize the benefits of the OTC benefit design.
number on the back of their member ID card. Group
If a member chooses to continue with a prescription
leaders may contact the group leader line at (651) 662-1725
version of a drug that has been removed from the
or toll free at 1-877-293-7035.
formulary, the drug will not be covered.
Prime Therapeutics is an independent company providing pharmacy benefit management services. Why is Blue Cross making these changes? Blue Cross works on behalf of our customers to continually drive better value for health care dollars. As market-leading drugs in these therapeutic classes have become available in OTC form at a fraction of their prescription price, there is great opportunity to provide increasing value for the health care dollar.
Covering brand-name drugs challenges the affordability of all drugs by driving up the overall cost of prescriptions. Excluding certain drugs that have effective, more affordable counterparts better aligns incentives for members to use preferred drugs at a better value.
How will members experience this formulary change? All Blue Cross members affected by this change will receive a letter by June 1, 2008, explaining these changes. Members currently taking a drug that is being moved to a non-covered status can contact their doctor for a new prescription of the OTC version. Or, members can work with their pharmacist, who can call the doctor on their behalf. The doctor will decide which OTC version is right for the member. If members choose to remain on the non-covered drug, members should expect to pay the entire cost and the dollars will not apply to the members’ deductible and/or out-of-pocket maximum.
Blue Cross and Blue Shield of Minnesota • P.O. Box 64560 • St. Paul, MN 55164-0560
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