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(On and Off Exchange)

(Must have compatible plan)

(Must have compatible plan)

for Marketplace plans

through UnitedHealth One

through BCBSTX

through GeoBlue

972.245.0266 | 888.456.3467 972.245.2455 (fax) Mobile App

NOTE: The following announcement applies to Blue Cross Blue Shield of Texas ACA-compliant individual, small group, and mid-market plans but NOT to grandfathered or transitional small group plans (there are no significant changes to the formularies or preferred pharmacy networks for those plans at this time).

EFFECTIVE JANUARY 1, 2017: Pharmacy changes have been made in the Regulated Small Group 2-50 Marketing Segment & Non Regulated Middle Market Segment 51-150 for 2017. Blue Cross Blue Shield, Texas (BCSTX) reviews the prescription drug benefit program annually to ensure the program is on target with current health care trends, while controlling prescription drug costs for our members.

As stated in the August 18, 2016 News from the Blues, “BCBSTX continually assesses our pharmacy networks to ensure we are maintaining affordable benefits for our members, including obtaining competitive reimbursement rates from participating pharmacies. Through ongoing negotiations, CVS Pharmacy requested a higher reimbursement rate for generic prescriptions as compared to other pharmacies. Therefore, Effective January 1, 2017, regardless of renewal date, CVS pharmacies and CVS pharmacies in a Target store will no longer be a part of the BCBSTX pharmacy network.” This NFTB edition is included to provide you with more information.


Beginning January 1, 2017, All small group and individual metallic plans will experience a change to their Preferred Retail Pharmacy Network which allows members to pay the lowest copayment at a network of pharmacies designated as preferred. The preferred pharmacy network includes:

  • Walgreens
  • Walmart (including Sam’s Club Pharmacy)
  • Albertsons (including Tom Thumb, Market Street, Randall’s, United Pharmacy, Amigos, Safeway, Vons, Super Saver and many other grocery stores under the Albertsons corporate banner)*
  • HEB
  • Access Health (a group of independent pharmacies)*

*A list of all participating pharmacy locations is available on

Non Regulated Middle Market Plans 51-150 will move to the Preferred Retail Pharmacy Network that the small group 1-50 segment has utilized during 2016. This network change allows members to pay the lowest copayment at a network of pharmacies designated as preferred and their overall savings for generics is $5 and for brand name it is $10. Coinsurance/HSA plans receive a 10% differential when using the Preferred Retail Pharmacy Network.

A 90 day supply at Retail Pharmacies will only be available at the Preferred Network Pharmacies. A 90 day supply will be at 3X retail copay. The mail order through Prime will also be 3X the copay or if an HSA, the cost for 3 months.
Disruption letters will be sent to impacted members who are affected by these changes Members affedted by this network change will be sent letters 60 days prior; they will also receive an introduction postcard informing them how they can pay less for their medicines by using an in network pharmacy. Reminder letters will be sent on an ongoing basis.

**** Members pay a lower copay at a non preferred pharmacy which would be a pharmacy that is not listed above ****


The Formulary list for all Regulated Small Group Metallic Plans for 2-50 & Non Regulated Middle Market Plans 51-150 will be the Performance Formulary effective 1/1/17 for new groups or at the 2017 renewal for existing business.

The Performance Formulary is a closed drug list and certain brand name drugs will not be covered if they have a therapeutic generic or brand name alternative. It includes both specialty and non specialty drugs for all major therapeutic categories. This change will lead to higher generic utilization and fewer choices in the preferred brand category. It will lead to a high savings potential and lower net cost for our members. The Closed Formulary has NO non-preferred brand name category: there is only generic and brand name. A drug that does not appear on the Performance Formulary is a non-covered drug and members should speak to their physician about the appropriate therapeutic alternative for them. All available covered drugs will be shown on the Performance Formulary which should be available by December 2016. Drugs not on the list are not covered.

Top Performance Formulary Exclusions

  • Abilify
  • Absorica
  • Amitiza
  • Androgel
  • Benicar HCT
  • Dymista
  • Leuprolide Acetate
  • Nucynta
  • Onexton
  • Pazeo
  • Pennsaid
  • Proventil HFA
  • Pulmicort Flexhaler
  • Qnasl
  • Tudorza Pressair
  • Veramyst
  • Vytorin
  • Xopenex HFA
  • Zovirax

Pharmacy Benefit Exclusions (Unchanged from 2016)

  • Compound drugs
  • Weight Loss
  • Impotency
  • Infertility
  • OTC Equivalents
  • Any drug not listed in the drug list, also known as formulary list.

Other Pharmacy Benefit Considerations

  • Insulin / Syringes: a separate copay applies for BOTH even if filled on the same day.
  • Oral oncology- $0 copay for oral cancer medications.
  • 30 day supply limit at non-network retail / 90 day supply available only at preferred retail pharmacy network and at Prime mail.
  • Specialty drugs are limited to a 30 day supply.
  • Vaccines covered at participating retail pharmacies.
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