To better manage our prescription drug costs and to ensure that we can continue offering you the coverage you value, JHU will introduce new prescription drug programs through Express Scripts to help you get the right prescription at the best price. These changes will affect participants enrolled in a CareFirst BCBS plan or EHP medical plan, effective Jan. 1, 2018.
The following programs will be introduced at that time. These changes may apply to any existing prescriptions you may be refilling each month and will apply to any newly filled prescriptions on or after Jan. 1:
Mandatory generics—member pays the difference (applies to all prescriptions). Generic drugs are lower-cost medications that are just as effective as brand-name drugs. If you purchase a brand medicine when a generic-equivalent drug is available, you may pay more—the generic co-pay plus the difference in cost between the brand and generic drugs. You will receive a letter from Express Scripts in late November if you currently have a prescription on file that is affected by this change.
Prior authorization (applies to new prescriptions in certain drug categories after Jan. 1; current prescriptions are grandfathered while in continuous use). Some medications will require prior authorization, or review and approval, before the plan will cover the cost. This is to ensure that the medication you receive is safe and effective for your situation. Prior authorization may be required for drugs that:
- Have potentially dangerous side effects
- Are harmful when combined with other drugs
- Are often misused
- Are prescribed when less expensive drugs are as effective
- Are specialty medications that are meant to treat very specific diseases and require appropriate clinical markers (biological characteristics that help assess whether a drug will be effective in a specific patient)
Step therapy (applies to certain new prescriptions after Jan. 1; current prescriptions are grandfathered while in continuous use). Step therapy requires you to try lower-cost (often generic) medications before "stepping up" to medications that cost more. If your medication requires step therapy, you will be obligated to try a step-one medication before "stepping up" to a step-two (or -three) medication. Step-one alternative medications are proven to be safe, effective, and affordable, and they can provide the same health benefits as more-expensive medications at a lower cost to you.
For example, imagine you are experiencing symptoms of heartburn:
- Step 1: You try an over-the-counter medication for your heartburn, but it doesn't control your symptoms. So, you consult your doctor.
- Step 2: Your doctor prescribes a step-two medication (a low-cost prescription drug). The step-two drug does not relieve your symptoms.
- Step 3: Your doctor prescribes a step-three medication that's more expensive and works for your symptoms.
Quantity limitations (applies to all prescriptions). To reduce waste and ensure that the most cost-effective product strength is prescribed, certain medications will be subject to quantity limitations (as determined by the Food and Drug Administration). If your treatment exceeds the quantity limitation of your drug, your prescription will require further authorization. Express Scripts will send you a letter in late November if you are affected by this change for future refills of your medication.
If your medication needs approval, either you or your pharmacist will need to let your doctor know. Your doctor can switch your prescription to another drug that doesn't require prior authorization, step therapy, or quantity limitations or can call Express Scripts at 888-406-1213 to start the approval process.