New Custom Select Drug List available Jan. 1

Blue Cross Blue Shield of Michigan and Blue Care Network have developed a new Custom Select Drug Listthat will be used for all BCBSM and BCN small group and individual members in 2014. This new Custom Select Drug List is roughly based on our Custom Drug List (previously called the Custom Formulary), but provides lower cost and better value for our customers’ health care dollars. 

Several drugs and drug categories will be excluded from coverage under the new benefit. These include the following:

• Brand-name drugs that have generic equivalents
• Over-the-counter medications (unless considered preventive by the United States Preventive Services Task Force)
• Lifestyle drugs (drugs used for erectile dysfunction or weight loss)
• Cosmetic drugs
• Drugs used for coughs and colds
• Most nonsedating antihistamines
• Most proton pump inhibitors, except select generic versions
• Prenatal vitamins
• Compounded drugs, with some exceptions

In addition to the changes in coverage, BCBSM and BCN small group and individual members will see a change in their copayment structure. BCBSM members will have either a three-tier or five-tier drug benefit, while BCN members will have a six-tier drug benefit. This applies to all members who enroll through the Health Insurance Marketplace, those who purchase directly from the Blues or members whose employers choose the new, less expensive Custom Select Drug List.

Below is a description of our new prescription benefit structure that we’ll use for the Custom Select Drug List.

Tier 1: Generics — Lowest drug copayment
All drugs in this category are generic drugs. Members pay the lowest copayment for generics, which makes them the most cost-effective options for treatment. BCN groups generic drugs into two tiers:

• Tier 1A (lowest generic copayment) includes preferred generic drugs to treat chronic diseases like high blood pressure, high cholesterol, diabetes, heart disease, certain eye diseases, depression and congestive heart failure.
• Tier 1B (highest generic copayment) includes other covered generic drugs.

Tier 1A and 1B only apply to BCN. BCBSM covers generic drugs at a Tier 1 copayment.

Tier 2: Preferred Brand — Higher copayment
This category includes preferred, brand-name drugs. These drugs are more expensive than generics, and you’ll pay a higher copayment for them.

Tier 3: Nonpreferred Brands — Highest brand-name copayment
In this category are nonpreferred brand-name drugs for which there is either a generic alternative or a more cost-effective preferred brand. You will pay the highest nonspecialty drug copayment for these medications.

Tier 4: Preferred Specialty — Lowest specialty drug copayment
Specialty drugs in Tier 4 are generally more effective and less expensive than nonpreferred specialty drugs in
Tier 5.

Tier 5: Nonpreferred Specialty — Highest specialty drug copayment
Members pay the highest copayment for specialty drugs in Tier 5. That’s because there may be a more cost-effective generic or preferred brand available.

The new Custom Select Drug List will be available online by Jan. 1, 2014.           

The information in this document is based on preliminary review of the national health care reform legislation and is not intended to impart legal advice. The federal government continues to issue guidance on how the provisions of national health reform should be interpreted and applied. The impact of these reforms on individual situations may vary. This overview is intended as an educational tool only and does not replace a more rigorous review of the law’s applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice.