Members can find out drug prices with this new benefit HERE.
Effective July 1, 2017, MUST’s pharmacy benefit will be managed by Prime Therapeutics. Prime uses a Performance Drug List and Advantage Plus Pharmacy Network to provide members with a managed selection of pharmacy choices. This is a new pharmacy benefit with a different formulary, network, management strategies, and clinical policies. Existing URx prior authorizations are not grandfathered and will not be carried over from the previous benefit. CVS/Target pharmacies are out-of-network, however, all Montana cities with CVS/Target pharmacies will have alternate in-network options available.
LINKS & INFORMATION
RM, CM & BLUE Options
The pharmacy benefits detailed below are included in the Revised Major Medical (RM), Comprehensive Major Medical (CM), and Blue Options (BO) plans. Members on the Basic Plan can use the MUST ID card for certain pharmacy discounts. The card must be provided at the point of service, with ACA preventive prescriptions covered at 100%.
IMPORTANT NOTE: To assist with the transition to Prime, members that may experience benefit change(s) will receive letters from BCBSMT/Prime Therapeutics. These letters are focused on potential Performance Drug List (formulary) disruptions, coverage limitations (i.e. prior authorization) and specialty medication utilizers. The letters are to help members become aware of changes and to be proactive.
Members taking specialty medications, and possibly other instances, may receive phone calls. For example, calls from Prime Specialty Pharmacy may display on caller ID as Toll-Free with the number, 877-627-6337. Prime Specialty Pharmacy will also be notifying certain members regarding additional disease management services that may be available. Calls from BCBSMT may also occur.
Prime has over 55,000 participating pharmacies nationwide with over 240 of those in Montana. Some retail pharmacies can provide 90-day supplies. Members may use mail order benefits through Prime Mail at www.myprime.com, Ridgeway or Costco Pharmacy. Diplomat Specialty Pharmacy is out-of-network on this new pharmacy benefit.
Specialty medication utilizers must transition to Prime Specialty Pharmacy and prior authorization/step therapy is likely required before coverage. Diplomat Specialty Pharmacy is out-of-network.
The plan includes new utilization clinical management programs. Authorizations approved on URx will not be forwarded to the new plan. These programs include:
- Prior Authorization: Appropriateness of use
- Step Therapy: Lower cost therapeutic equivalents
- Dispensing Limits: Eliminates waste
- Check the Prime Performance Drug List for drug coverages and limitations (to ensure drug coverage and be aware of utilization management programs). All covered prescription medications are on the drug Medications not on the list are not covered.
- Check the Prime Advantage Plus Pharmacy Network for contracted pharmacies. CVS-owned® pharmacies and CVS pharmacies in Target® stores are not in your pharmacy network.
- It is recommended that all members attempt to refill prescriptions by 6/30/17 to aid in the transition.
- Under your new benefit, members should refill early (2 weeks) to ensure proper processing of your first fill.
If you have questions about prescriptions, utilization management, need to find a pharmacy, estimated drug costs, or want to view the Advantage Performance Drug List, please visit www.myprime.com.
|PERFORMANCE DRUG LIST TIERS||30 DAY MEMBER CO-PAY FOR NON-HDHP PLANS*|
Pharmacy Out-of-Pocket Max.
90-DAY (MAIL ORDER OR AT RETAIL): 3X Co-pay
*Member responsibility will be the lower of the contracted rate or the copay
Members on High Deductible Health Plans (HDHPs) will pay 100% of the cost of their medications until their medical plan deductible is met. All HDHP plans include an Expanded Preventive Drug List, which covers additional preventive prescriptions at $0 before deductible. The preventive drug program currently includes prescription drugs in the following categories: anti-coagulants/anti-platelets, bowel preparation, breast cancer prevention, contraceptives, diabetes medications and supplies, fluoride supplements, high blood pressure, high cholesterol, osteoporosis, respiratory, tobacco cessation, and vaccines.
Includes standard ACA $0 preventive drugs.
Members on the Basic Plan can use the MUST ID card for certain pharmacy discounts. The card must be provided at the point of service. ACA preventive prescriptions are covered at 100%.
Mail-Order Programs for Ongoing Medications
You can obtain a 90-day supply of medication through a mail-order program with Ridgeway Pharmacy, Costco Pharmacy, or Prime Mail. You can access information for the mail-order program through their websites or by contacting them directly at the numbers listed below. With the mail-order program, medication will be delivered to your mailing address. Members who have not yet signed up with one of the mail-order pharmacies must do so using the applicable form found above.
- Costco Pharmacy | Telephone: 1-800-607-6861 | Website: www.pharmacy.costco.com
- Ridgeway Pharmacy | Telephone: 1-800-630-3214 | Website: www.ridgewayrx.com
- Prime Mail | Telephone: 1-877-357-7463 | Website: www.myprime.com
Specialty Pharmacy Program
This program helps deliver specialty medications directly to physicians or to members that include injectable and infused therapies used to treat complex medical conditions.
For the benefit of MUST members, Blue Cross and Blue Shield of Montana (BCBSMT) contracts with the select specialty pharmacies to ensure availability of specialty medications. The benefits of obtaining self-injectable specialty medications from these preferred specialty pharmacies include:
- Integrated coordination of coverage between the member, physician and BCBCMT
- No up-front acquisition cost to physicians for non-self-administered/office-based specialty medications
- Convenient delivery of medication to physician’s office or member’s address
- Injection supplies with every shipment, including alcohol swaps, needles and syringes
- Automatic coordination of refills
- Patient education materials and therapy starter kits from drug manufacturers
- 24-hour hotline staffed nurse and/or pharmacist to call with medication and injection questions
Blue Access for MembersSM (BAMSM ) and MyPrime.com – online tools to help guide you through your prescription drug benefits.
Starting July 1, 2017, you can view your specific prescription drug benefit plan information by registering or logging in to your BCBSMT BAM account from bcbsmt.com. Once in BAM, select Prescription Drugs in the Quick Links section to link to your own account on MyPrime.com, the Prime member website. MyPrime.com offers resources and tools to help you manage your new prescription drug benefit.
For questions related on your pharmacy benefits or to contact Member Services, call 1-800-423-1973.