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Blue Access for Producers

Three-tier Formulary Coinsurance


Product Summary
The three-tier formulary coinsurance program is designed to save members and employers money through utilization of lower-priced generic and formulary drugs obtained through contracting pharmacies. Discount arrangements with pharmacies may lower the price members pay for prescription drugs. Any resulting cost savings can then be passed onto employers through lower claim costs.

Coinsurance and Contracting Pharmacies
The coinsurance drug card program provides cost containment based on member share. By paying a percentage of the cost, members are more aware of the cost of prescription drugs. The coinsurance percentage amount is lowest for generic drugs, the same or slightly higher for formulary brands and the highest for non-formulary brands. There is a minimum cost of $10, and a maximum cost of $75 per prescription, when employees use a contracting pharmacy. Blue Cross and Blue Shield has contracted with more than 99 percent of Illinois pharmacies and more than 56,000 pharmacies nationwide.

The Formulary
The formulary is a list of preferred drugs selected by a nationally recognized panel of physicians and pharmacists. Medications are evaluated on their comparative efficacy, safety, uniqueness and cost effectiveness. The formulary is updated quarterly, and generic medications are added as they become available.

Non-HMO Mail Service Prescription Drug Program
The mail service benefit gives members the convenience and cost-savings of having a 90-day supply of a maintenance medication delivered to their home. The appropriate coinsurance level applies based on generic, formulary or non-formulary brand drugs.

HMO 90-Day Supply Program
The 90-day supply program gives members the option to obtain a 90-day supply of maintenance medication at a retail pharmacy or through a mail service pharmacy. Members can save both time and money when using a 90-day contracting pharmacy for their maintenance medications. The appropriate coinsurance level applies based on generic, formulary or non-formulary drugs.