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 November 1, 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:

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