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BCBS allows exceptions to generics decision

March 29, 2011

Remember last month when I did a story about Blue Cross Blue Shield’s changes to its prescription plans?

Here’s the summary of the issue- last November, Blue Cross Blue Shield of Rhode Island decided to cut costs by not paying for brand name drugs when there was a cheaper generic version. But some residents say there are no alternatives to the medications they need. Now they’re faced with paying the full market price or going without their medicine.

We met Catherine Lewis, a woman with severely dry eyes who could only treat her condition with prescription strength eye drops called Restasis.  When BCBS took Restasis off its list of drugs it would pay for, there was no generic version and she faced a price tag of  $340 for a month’s supply.

Well, BCBS has decided to change its policy.  The health insurance plan now has a “medical exception process” where patients can argue that they need the name brand version of a drug when no generic will work.  This is how BCBS explains the process-

• The healthcare provider must apply for an exception on the patient’s behalf.
• The provider must fill out the appropriate medical exception form for the
drug prescribed and submit it to CVS Caremark, our pharmacy benefits
manager.
• The provider must give a medical reason for the member to stay on an
excluded drug.
• CVS Caremark will review the exception application according to normal
utilization review guidelines and protocols.

Included in the new policies is a list of drugs that qualify for the exemption process. And yes, Restasis is one of them.

The new process takes affect on April 1st.  Some patients who’ve been paying out of pocket for excluded drugs might also qualify for retroactive exceptions.

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