Tiering and formulary updates for Medicare members: 

• 470 drugs moving off formulary 
• 936 drugs moving to Higher Tiers

Tiering changes

• 137 drugs moving from Preferred Generic to Generic 
• 38 drugs moving from Preferred Generic to Preferred Brand tier 
• 320 drugs moving from Generic to Preferred Brand tier 
• 125 drugs moving from Generic to Non-Preferred Brand tier 
• 282 drugs moving from Preferred Brand to Non-Preferred Brand tier 
• 12 drugs moving from Preferred Brand to Specialty tier 
• 22 drugs moving from Non-Preferred Brand tier to Specialty tier
• Members have rights to the tier exception process for Tiers 2-4

Other changes

• 38 drugs added to formulary
• 96 drugs moved to lower tiers

For a detailed list of changes, please click here. 

For drugs that are moved off the formulary, where appropriate, please consider switching members to a covered alternative. For members who cannot use a covered alternative please request a coverage exception through Prime Therapeutics. Members impacted by negative formulary changes will be eligible for a transition fill during the first 90 days of the new plan year to allow time for medication changes and/or the coverage exception process.

Coverage exceptions

You can ask us to make exceptions to our coverage rules. There are several types of exceptions that you can ask us to make:

• You can ask us to cover a drug that is not on our formulary.
• You can ask us to waive a restriction to a drug that is on our formulary.
• You can ask us to change coverage of a drug to a lower cost-sharing tier. For example, changing a non-preferred drug to a preferred drug cost-share.

How fast will a decision be made?

For a coverage determination, our plan is required to provide a decision within 72 hours of receiving the prescribing physician’s supporting statement. However, if a member’s health requires a faster decision, you can request an expedited coverage determination, and we will provide you a decision within 24 hours after we get the prescribing physician’s supporting statement.

Use the following link to start the exceptions process:

Helping People get the Medicine They Need | CoverMyMeds

2025 exception reviews can be submitted as of 1 de novembro, 2024.

Helpful online resources 

Did you know that all our Medicare formularies and utilization management (UM) criteria are available online? The formulary is a great tool to help members and providers understand what drugs the plan covers; which of these drugs have UM edits, such as prior authorization, quantity limit, and/or step therapy; and which drugs in the same therapeutic category do not have UM. 

Click the below link to explore our formularies and UM criteria:

Farmácia | Blue Cross & Blue Shield of Rhode Island (bcbsri.com)