Important Information About Your Prescription Benefit Changes Effective
October 1, 2013
Topeka Public School employees will be covered under BCBSKS prescription
coverage. New ID cards will be issued for all employees.
The pharmacy will file claims for you, and you will pay only your copayment amounts to the
pharmacy at the time of purchase. You must show your Blue Cross and Blue Shield of Kansas
(BCBSKS) identification card to the pharmacy at the time of your purchase.
We want to help get you the medicine you need to live well. BCBSKS helps hold down costs for
you and your employer and encourages appropriate drug use through utilization management
programs. These programs are designed to ensure members receive safe, cost-effective drugs.
Utilization management programs include quantity limits, step therapy, prior approval programs
and use of generic and over-the-counter drugs instead of more expensive brand name drugs. A
panel of pharmacists and physicians reviews these programs to ensure quality health care is
never sacrificed for cost.
Copayments
Retail - $15 Generic, $30 Brand Name Formulary, $45 Brand Name Non-Formulary
Mail Order - $37.50 Generic, $75 Brand Name Formulary, $112.50 Brand Non-Formulary
Days Supply Limitations
There are limits on the quantity of a drug that will be covered each time you fill your
prescription. For most drugs, you will be able to receive a quantity sufficient for up to a 34 day
supply.
If your drug is defined as a "maintenance" drug by BCBSKS, you will be allowed a 100 dosage
unit supply for one copay at the Retail pharmacy. A list of the "therapeutic" class of drugs
defined as maintenance by BCBSKS is available at www.bcbsks.com.
For those prescription drugs that are not defined as a "maintenance" drug, you can order up to a
90-day supply of medication at one time by using PrimeMail. To obtain more information on
how to begin using the mail order program, please go to www.bcbsks.com.
Specialty drugs are always limited to a 34 day supply. A complete list of specialty drugs is
available at www.bcbsks.com or by contacting customer service at the number on your
identification card.
Quantity Limits (Identified by “QL” on prescription drug formulary)
Quantity limits are designed to limit the use of selected drugs to ensure quality and safety while
reducing waste. Drugs with quantity limits include Ampyra, Kalydeco, Firazyr, testosterone
products, oxycodone extended release (Oxycontin) and those used in treating migraine headaches
and erectile dysfunction.
Groups Transitioning to a BlueRxCard Benefit
Mandatory Generic
The mandatory generic benefit is utilized to increase generic utilization by providing a
disincentive to members who choose to purchase brand name drugs when a generic equivalant is
available. A member who chooses to purchase a brand name drug that has a generic equivalent
will pay the brand name copay of $45, plus the difference between the allowed cost of the brand
and the allowed cost of the generic.
If the Physician has determined the brand name drug is necessary for the member and indicates
"dispense as written" (DAW) on the prescription, the member would be eligible to purchase the
brand name drug and only be responsible for the $45 copay.
Excluded Drugs (Excluded Drugs are listed on the formulary)
Brand name prescription drugs in selected classes are not covered. These classes have multiple
generic prescription drugs or over-the-counter (OTC) alternatives that provide effective
treatment at a lower cost. A prior approval process is not available for coverage of these
brand name products. The affected drug classes include:
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Nutritional Products: dietary supplements
Non-Sedating Antihistamines (NSAs): treat hay fever or other allergies (brand drugs
not covered include Clarinex, Clarinex-D, Semprex-D, Xyzal and brand name drugs
available OTC)
Proton Pump Inhibitors (PPIs): treat acid reflux disease, heartburn or ulcers (brand
drugs not covered include Aciphex®, Dexilant®, Nexium®, Prevacid®, Prevacid
Solutab®, Prilosec®, Protonix®, Vimovo® and Zegerid®). OTC Prilosec will no longer
be covered, but generic for Prilosec, omeprazole, will be covered, if prescribed. Other
prescribed generics, pantoprazole and lansoprazole are also covered.
Statin Drugs: treat high cholesterol (brand drugs not covered include 1.) Lipitor,
2.) Lescol, 3.) Mevacor, 4.) Pravachol and 5.) Zocor). Covered drugs are the prescribed
generic equivalents to the above Non-Covered brands: 1.) atorvastatin, 2.) fluvastatin,
3.) lovastatin, 4.) pravastatin and 5.) simvastatin. The brand name drug Crestor does not
currently have a generic equivalent and if prescribed, could be covered with a prior
authorization approval or trial of a generic drug.
Tetracycline Antibiotics: treat acne and other infections (brand drugs not covered
include Adoxa, Alodox, Avidoxy, Doryx, Dynacin, Minocin, Monodox, Nutridox,
Ocudox Kit, Oracea, Oraxyl, Periostat, Solodyn, Vibramycin). Covered drugs are the
prescribed generics, minocycline and doxycycline.
Step Therapy Drugs (Identified by “PA” on prescription drug formulary)
Step therapy programs encourage the use of generic medications before more expensive brand
name medications. As the cost between brand and generic drugs typically exceeds $100 per
month, step therapy programs encourage selection of equally safe and effective generic
medications that minimize cost for the employer and employee alike. Depending on your benefit
and drug utilization, generics can reduce member out-of-pocket expense by $150-$500 annually.
Groups Transitioning to a BlueRxCard Benefit
Drugs requiring step therapy include drugs to treat high blood pressure, high cholesterol and
depression. Members who are new to therapy are required to have a trial of a generic product
prior to having coverage for a brand product, or complete a physician initiated prior approval
(PA) process. Brand name “Statin” drugs, listed above, that have a generic available are not
covered.
Prior Approval Drugs (Identified by “PA” on prescription drug formulary)
Prior approval (prior authorization) requires that certain drugs are used according to recognized
guidelines of appropriate use. Many of these are expensive specialty drugs used to treat small
populations of patients. Your physician must initiate the prior approval process. Drugs requiring
prior approval are:
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Adult and pediatric growth hormone – members will be required to use the preferred
growth hormone product, Omnitrope, before another growth hormone product will be
approved.
Celebrex - used to treat osteoarthritis
Testosterone and anabolic steroids - with topical products requiring use of preferred
brands, Androderm and Androgel, before use of non-preferred topical products.
Ampyra® - used to increase walking speed for patients with multiple sclerosis
Biologics - used to treat autoimmune diseases such as rheumatoid arthritis, Crohn’s
disease and psoriasis
Drugs used to treat Hepatitis C - members will also be required to use preferred
interferon drugs prior to approval of non-preferred drugs
HP Acthar Gel - used to treat infantile spasms
Interferon drugs - used to treat multiple sclerosis; members will be required to use
preferred drugs prior to approval of non-preferred drugs
Kalydeco - used to treat cystic fibrosis
Prolia and Xgeva - used to treat osteoporosis
Self-administered Oncology agents
Synagis - used for RSV prevention in infants
Xolair - used for asthma
Prescription Drug Benefits and Formulary Information
More information about prior approval (prior authorization), excluded drugs, specialty drugs and
quantity limits, including drug names, and the BCBSKS medical policy used for prior approval is
available at:
www.bcbsks.com/CustomerService/PrescriptionDrugs/index.html.
If you have any questions, please call Customer Service at 1-800-432-3990.
Groups Transitioning to a BlueRxCard Benefit