The Record - for physicians and other health care providers to share with their office staffs
May 2010

Prescription drug supply, refill requirements change

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Blue Cross Blue Shield of Michigan will soon make changes to our prescription drug benefits. These changes will offer an additional drug safety measure for our members and cost savings to our group customers.

The following pharmacy initiatives are effective July 1, 2010:

  • Standard retail supply change: Our standard retail 34-day supply limit will change to a 30-day supply limit. We are bringing our prescription drug coverage in line with the industry standard. We understand that our average customer fills a prescription for less than 30 days, and most physicians write prescriptions for a 30-day supply.

    The following are exempt from this change:
    • Customers groups will still be able to get a retail 90-day supply through our 90-day retail benefit.
    • Members will still be able to get a higher supply amount for drugs on the Blue Cross Maintenance Drug List if this benefit applies to the member.
  • Specialty drug supply limits: The initial fill of a select number of highly potent specialty drugs will be limited to a 15-day supply. We want to ensure our members are not paying for drugs they ultimately cannot use, and do not feel obligated to use drugs that may have adversely affected them just because they’ve already purchased a full-month supply.

    Initially, we will only be targeting four highly potent oral oncology drugs. They are Sutent®, Tarceva®, Nexavar® and Revlimid®.

    If the member is able tolerate the drug, he or she can then can then go back to the pharmacy to get the remaining 15-day supply or, if he or she chooses, get the standard 30-day supply.

    Members who are already established on the drug therapy of one of these drugs, meaning they have received at least a 15-day supply in the past 180 days, will not be subject to this limitation. They can continue to receive a full 30-day supply all at once. If Blue Cross does not have the member’s claims history, and the member is currently taking one of these medications, our system will not be able to automatically “grandfather” the member. The member’s pharmacist or the physician will have to request an override to allow a full 30-day supply to process normally. The pharmacist or physician should call our Pharmacy Services clinical help line at 1-800-437-3803.

  • Prescription refill requirement: We’re increasing the wait time between prescription refills. Blue Cross members who currently have a 66.6 percent refill requirement will now have a 75 percent requirement.

These pharmacy initiatives affect both local and NASCO Blue Cross groups, except MESSA and the State of Michigan. Blue Care Network groups are also not affected. For more information, contact your Blue Cross provider consultant.

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