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Are Your Prescriptions Covered? The Latest on Prescription and Pharmacy Changes for 2017

By Ryan Vulcan | October 17, 2016 | Healthy Lifestyle, Insurance Education

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You’ve seen it on the news, read it on our blog and felt the pinch at the pharmacy:  rising drug costs are a top health care concern among consumers and insurers. In 2015 alone, just the three most expensive drugs cost BCBSNC $190 million to cover1.

In order to keep premiums and prescription prices as low as possible, BCBSNC and other health insurers across the country are taking steps to rein in costs.

Two changes that we are making to pharmacy plans in 2017 will affect existing:

  • Pharmacy Networks
  • Covered Drug Lists (Formulary)


These changes only impact individual customers under the age of 65 who purchase their own health insurance (not through their employer). It is important to consider these changes when selecting an individual ACA plan for 2017.

We realize that it can be confusing and sometimes frustrating trying to keep up with these changes each year. Here are a few steps you can take to ensure you choose the right plan for your health needs.



Step 1


Is your current pharmacy in-network?

Some pharmacies will be out-of-network in 2017. Check to see if the pharmacy you currently use is in-network. If not, you’ll need to switch to an in-network pharmacy before January 1, 2017, to get discounted member prices, or choose another plan that meets your pharmacy needs.

Limited Pharmacy Network*

2017 prescription changes
*Please note: These pharmacy networks are accurate as of 12/16/16. And updated since the blog was originally posted on 10/17/2016. Pharmacies can opt to change their participation until 12/31/16.

What you can do

You can keep using an out-of-network pharmacy, but keep in mind:

  • If your health plan has out-of-network pharmacy benefits, you’ll pay the full cost for your medications and need to submit a claim for repayment. Remember, your prescription costs may be much higher than the in-network amount.
  • If you have a health plan without coverage for out-of-network pharmacies, you’ll have to pay the full cost of your medications.



Step 2


Get to know the new drug list

To help keep costs down, your plan uses a list of covered drugs called a formulary. In 2017, BCBSNC plans have a six-tier formulary rather than the five-tier formulary for 2016 plans. All covered prescription drugs fall into one of six categories or tiers. If the drugs you take are on the new Tier 6, your out-of-pocket costs for these drugs may change with your 2017 plan.

Pharmacy benefit plans that use the Essential Formulary focus on the safe and effective use of generic drugs. These plans cover selected brand-name drugs for certain drug classes, but for several classes, only generics are covered.

In June, Prime Therapeutics, which manages prescription drug coverage for insurers and employers including BCBSNC, explained in a blog post that tiered plan designs are one of our most powerful tools to lower your overall drug costs.

Below are examples of drugs from 2016 and 2017 Tiers to help you understand these changes.

2017 prescription changes


What you can do

Ask your doctor to change your prescription to a drug with the same therapeutic effect that is covered by your plan. If you have questions, you can search our list of covered medications.



Step 3


Other coverage changes

Under your new plan you may need:

  • Prior authorization from a doctor
  • To try other medications first


What you can do

Check your current medication supply before your 2016 plan ends and your 2017 plan begins and refill your prescriptions if needed. This will help ease your transition to the new plan’s pharmacy benefits.


  1. Humira, Harvoni and Enbrel. BCBSNC claims data, 2014-2015.