Formulary (List of Drugs) - BCBSIL

1 Formulary (List of Drugs) Effective Date: 01/01/2022 03/31/2022 Member Services: 1-877-860-2837 (TTY/TDD: 711) IL_BCCHP_RX_FORMULARY20 approved 09292020 Member Services: 1-877-860-2837 TTY/TDD: 711 24/7 Nurseline: 1-888-343-2697 i WHEN YOU NEED TO CONTACT MEMBER SERVICES Our goal is to serve your health care needs through all of life s changes. If you have any questions, our team stands ready to help. Call 1-877-860-2837 (TTY/TDD: 711) We are open 24 hours a day, seven (7) days a week. The call is free. Website Blue Cross Community Health Plans c/o Member Services Box 3418 Scranton, PA 18505 Write ii Member Services: 1-877-860-2837 TTY/TDD: 711 What is the Blue Cross Community Health Plans (the Plan ) drug list?

2 The drug list (sometimes called a Formulary ) is a list showing the drugs that can be covered by the plan. The drugs listed will be covered as long as you: Have a medical need for them Fill the medication orders at an in-network pharmacy Follow the other plan rules For more information on how to fill your medication orders, please review your Member Handbook. What will I pay? You do not pay for covered drugs. Can the drug list change? Yes, it can change. Coverage may change if: A new, less expensive generic drug becomes available New information about a drug shows it to be unsafe or less effective You will be told in writing when the drug list does change. How do I use the drug list? There are two ways to find your drug in the list beginning on page 1.

3 1. Category The list of covered drugs that begins on page 1 gives you information about the drugs covered by Blue Cross Community Health Plans. If you have trouble finding your drug in the list, turn to the Index that begins at the back of this book. The first column of the chart has the name of the drug. Brand name drugs are capitalized ( , CIPRO) and generic drugs are listed in lower-case italics ( ciprofloxacin). o The information in the Necessary actions, restrictions, or limits on use column tells you if Blue Cross Community Health Plans has any rules for covering your drug. The drugs are listed in categories, or groups, based on the type of medical conditions they treat. (For example, drugs used to treat a heart condition are listed under Cardiovascular Agents).

4 If you know what your drug is used for, look for the group in the drug list. Then, look under that group for your drug. 2. Alphabetical Listing Look for your drug in the back of this book. Next to your drug, you will see the page number where you can find coverage information. Member Services: 1-877-860-2837 TTY/TDD: 711 24/7 Nurseline: 1-888-343-2697 iii What are generic drugs? A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug, but often costs less. The plan covers both brand name drugs and generic drugs. Are there any limits on my coverage? Added conditions or limits on some covered drugs may include: Prior Authorization (PA): You or your doctor may need to get approval before you fill your medication orders.

5 If you do not get approval, the plan may not cover the drug. Quantity Limits (QL): For certain drugs, the plan limits the amount that will be covered. Step Therapy (ST): In some cases, the plan requires you to first try certain drugs before another drug can be covered. For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. Age Limits (AL): Some drugs have limits based on the members age. This is a safety program to prevent harmful side effects. It follows age limits allowed by the FDA. Morphine Equivalent (ME) Dosing: ME dosing is a tool used to help prevent members from taking too much pain medication (opioids).

6 This tool allows Blue Cross Community Health Plans to calculate the total daily dose of pain medications a member is taking no matter which opioid they are prescribed. The current daily ME limit in Illinois is 120 mg per day. If you are taking a dose above ME120, you will need to get prior authorization for Blue Cross Community Health Plans to pay for the prescription(s). Specialty Pharmacy Split Fill Program (SF): Specialty drugs are certain prescription medications used to treat complex, chronic conditions like cancer, rheumatoid arthritis and multiple sclerosis. These drugs are an important part of many treatment plans. They can cause side effects which may lead to your doctor making changes to the dose or stopping the drug entirely.

7 As you go through treatment, your doctor may make changes to the treatment plan until the best dose is established for you. This may take a few months. The reason for the Specialty Pharmacy Split Fill Program for members newly starting therapy is to: Prevent unnecessary prescriptions at inappropriate doses Minimize waste of these drugs Manage side effects For the first 2 to 3 months of your treatment, you will be able to receive a 14- or 15-day supply of your prescription twice a month. Following the first 2 to 3 months of treatment and once the right dose has been established, you may start to receive a full 1-month supply for the rest of your therapy. iv Member Services: 1-877-860-2837 TTY/TDD: 711 You can find out if your drug has any added conditions or limits by looking at the list that begins on page 1.

8 You will find our contact information below, and the date we last updated the list on the back cover page. Providers may submit coverage exception requests by fax (1-877-243-6930), phone 1- 800-285-9426 (TTY/TDD 711), or by website ( or ). Providers may find forms on Does the plan pay for over-the-counter (OTC) drugs? Yes, the plan pays for certain OTC drugs with a valid medication order from your doctor, and you may get those at no cost. Generic products are to be prescribed and given out when available. These products are to be filled at a plan network pharmacy and for quantities up to a 30-day supply. What if my drug is not on the drug list? Contact Member Services and ask if your drug is covered. If you learn that the plan does not cover your drug, you have two options: Talk to your doctor to decide if you should first try a different drug on our list before you request an exception.

9 Ask Member Services about making an exception to cover your drug. Send in a statement from your doctor backing your request. We must decide within 24 hours of getting your doctor s statement. We usually only approve requests for exceptions if the other drugs included on our list or the added use limits would make your treatment less effective and/or would be harmful to your health. Which drug categories are not covered by the plan drug list? The following drug categories are not covered by your plan: Anorexia, weight loss, or weight gain drugs Bulk chemicals Cosmetic enhancing drugs Diagnostic agents Drug Efficacy Study Implementation (DESI) that are classified as ineffective Experimental and investigational drugs Erectile dysfunction drugs prescribed to treat impotence Fertility drugs General anesthetic drugs Over-the-counter products not otherwise included on the plan s drug list Surgical supply/medical devices Medications considered unreasonable, unnecessary, and/or excessive according to the standards of Medicaid, clinical practice guidelines, and FDA Services: 1-877-860-2837 TTY/TDD: 711 24/7 Nurseline.

10 1-888-343-2697 v For More Information For more details about your plan s drug coverage, please review your Member Handbook and other plan materials. If you have any questions, please call Member Services at: 1-877-860-2837 (TTY/TDD 711). We are available 24 hours a day, seven (7) days a week. The call is free. For Language Assistance Interpreter Services We can arrange for someone to help you speak with us in any language. These services are free. If your doctor does not speak your language, we can arrange for a translator to help you. Please call Member Services at the number above. Hearing and Vision Problems For our members with hearing problems, we offer TTY/TDD service free of charge. The line is open 24 hours a day/seven day a week at 711.