Oct 14, 2024
Blue Shield of California will be implementing an update to the outpatient pharmacy benefit for Large Group regarding member cost shares for brand drugs with generic equivalents available.
What is the cost share for brand drugs with generic equivalents today?
When a member chooses a brand drug over the generic, the member pays the difference in cost between the brand and generic drug in addition to the applicable tier cost share of the brand drug. This is in place to encourage generic utilization. When a provider chooses a brand drug over the generic, the member pays the applicable tier cost share of the brand drug.
What is the update
To further encourage generic drug utilization, starting on January 1, 2025, upon group renewal, the cost share for brand drugs with generics available will be the same, regardless if the member or the provider chooses the brand drug. Members will pay the difference in cost between the brand and generic drug in addition to the applicable tier cost share of the brand drug. This means some members may pay more when a brand drug is selected instead of the generic.
If the member switches to the generic drug, they will not pay the additional difference in cost between the brand and generic drug.
ASO (self-funded) & Custom Fully Insured Large Group plans may choose to opt out of this change at a higher premium cost.
What members can expect
Members who have recently filled a prescription for a brand drug and are impacted by this update will be notified in advance to encourage them to switch their brand drug to the generic option to avoid paying the additional difference in cost.
If the member or prescriber feels the brand drug is medically necessary, they may request an exception to allow the member to continue taking the brand drug without paying the difference in cost.
