2019 Prescription Drug Changes for Individual or Employer-Offered “Metallic” Plans

If you have a Blue Cross and Blue Shield of Montana (BCBSMT) "metallic" health plan now, changes to your 2019 pharmacy benefit program may start on January 1, 2019. You might see these changes if you bought your health plan on your own or get health coverage through your job.

Pharmacy Network Updates

The 2019 pharmacy network is made up of a nationwide group of contracting pharmacies. Just like with health coverage, you may pay more if you use an out-of-network location.

Value Pharmacy Network (VPN)

Your pharmacy benefits may have a Value Pharmacy Network (VPN). You’ll see the highest out- of-pocket savings when going to a VPN location.

Starting in 2019, these locations include:

  • Walgreens
  • Walmart
  • Albertsons (Osco Pharmacy, Safeway)
  • Health Mart Atlas (a group of independent pharmacies)
  • Pharmacy Providers of Oklahoma, Inc. (PPOK) (a group of independent pharmacies)

Your pharmacy costs may depend on where you go to get your prescriptions filled. Here’s a way to compare costs between your network choices:

In-Network Pharmacy
Value Pharmacies
Non-Value Pharmacies
Pharmacy cost is lower
Out-of-Network Pharmacy Pharmacy cost is higher
In-Network Pharmacy Pharmacy cost is lower
Non-Value Pharmacies
Value Pharmacies

Find a pharmacy. Please note that changes may be made to the participating pharmacies in the future.

Drug List Changes

Prescription drug lists have many levels of coverage, called payment level tiers. Your 2019 pharmacy benefit will have up to six payment level tiers.

Here’s a break-down showing each tier’s drug type and costs:

Payment Level Tiers

Generally, the lower the tier, the lower your out-of-pocket costs will be for the drug.

  • Tier 6: Non-preferred specialty
  • Tier 5: Preferred specialty
  • Tier 4: Non-preferred brand
  • Tier 3: Preferred brand
  • Tier 2: Non-preferred generic
  • Tier 1: Preferred generic

Note: Some brands may be in a generic tier and some generics may be in a brand tier.

Drugs that move to a higher payment level tier may still be covered. But, you may have to pay more out-of-pocket based on your benefits. Talk with your doctor if you have any questions about your prescription.

2019 Drug List Changes

Tab One Drugs No Longer Covered

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Drugs No Longer Covered

Some drugs will no longer be covered in 2019. Consider talking to your doctor about your options for covered generic or brand alternative drugs. Here you'll see lists showing:

  • Commonly used drugs that are no longer covered in 2019
  • Covered alternative choices for drugs not covered
  • All drugs that are no longer covered in 2019

Also, drugs that aren't U.S. Food and Drug Administration (FDA) approved are not covered.

Commonly Used Drugs No Longer Covered
CARISOPRODOL COMBIGAN EFFIENT ELIDEL EPIPEN/EPIPEN-JR
ESTRACE JUBLIA LIALDA METFORMIN ER 24HR OSMOTIC MINASTRIN
MOMETASONE FUROATE NASAL SUSP 50 MCG/ACT OLOPATADINE SOLN 0.2% OXYCONTIN PATADAY PAZEO
PRISTIQ RELPAX RENVELA RESTASIS STRATTERA
TAMIFLU TIROSINT TRANSDERM-SCOP VIGAMOX VIREAD
Tab pannel ends. Press down arrow or tab to move to the next tab

Tab Two Newly Covered Drugs

Tab pannel

Newly Covered Drugs

Coverage for new drugs added to your plan will begin when your plan renews or starts on or after January 1, 2019.

Sample List of Newly Covered Drugs
BELSOMRA EASY GEL GEL-TIN
JUST FOR KIDS GEL PERIOMED SILENOR
VEMLIDY    
Tab pannel ends. Press down arrow or tab to move to the next tab

Tab Three Utilization Management Programs

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Utilization Management Programs

Some medicines on your drug list may have special requirements. New drugs will be added to our utilization management programs when your coverage renews or starts in 2019.

Select each program name to see newly added drugs:

Step Therapy
You may need to prove you’ve been using a preferred drug before your plan will cover some other drug.

Prior Authorization
For some drugs, your doctor may need to ask BCBSMT for prior authorization before the drug may be covered.

Dispensing Limits
Your plan will only cover what the dispensing limit allows. These dispensing limits may include how much medicine per prescription fill or how many doses can be given over a period of time.

Tab pannel ends.

2019 Drug List

Here’s your 2019 drug list (for coverage that renews or starts on or after January 1, 2019):

Coupons for Individual Plan Members Only

If you use a drug manufacturer’s coupon or copay card to pay for a covered prescription drug, this amount will not apply to your plan deductible or out-of-pocket maximum (unless it is a permitted third-party cost sharing payment).

Pharmacy Benefit Reminders

Consider talking with your doctor, or pharmacist, about any questions or concerns you have about your prescribed medications. As always, pharmacy selections and treatments are always between you and your doctor. Only you and your doctor may decide what is right for you.

Coverage is based on the limitations and exclusions of your plan. For some drugs, you must meet certain criteria before prescription drug coverage may be approved.

Answers for Your Questions

As a BCBSMT member, here are ways you can learn about your pharmacy benefits:

Log in to your Blue Access for MembersSM (BAMSM) account

Log in to BAM

See your plan materials for pharmacy and prescription plan information

See Plan Information


Call the number on the back of your member ID card

Contact Us

Footnotes

  1. Members with a health plan provided through their employer will see these changes on their 2019 plan renewal date, unless otherwise listed.

  2. Value Pharmacy Network pricing isn’t available for 100% cost-sharing plans.

  3. You can also fill up to a 90-day supply of a covered drug at a retail pharmacy in the Value Pharmacy Network.

  4. Any additional charges you may pay will not apply to any of the out-of-pocket amounts (based on your plan).

  5. May not apply to all strengths/formulations. Third party brand names are the property of their respective owners.