+ context = "[SECTION] 📘 BlueShield Rx Policy Addendum: 2023–2025 Commercial & Employer-Sponsored Plans [SECTION] Confidential – Not for external dissemination without compliance review. [SECTION] 🔹 Section 2.1.7 – Drug Coverage Eligibility Matrix [SECTION] Prescription drug eligibility is governed by a tiered, multi-variant benefit design informed by annual P&T Committee decisions, manufacturer rebates, CMS Part D benchmarking (when applicable), and employer-specific customizations. The following formulary tiers apply unless superseded by a group rider or conditional override: [SECTION] - **Tier 1 (Generic Core):** Includes FDA-approved AB-rated generics; requires no PA or ST, unless the member is flagged under the Risk Management Tier Hold (RMTH) protocol due to prior misuse. [SECTION] - **Tier 2 (Preferred Brand & Enhanced Generics):** Coverage dependent on documented trial/failure of Tier 1 alternatives unless contraindicated. Members in the Legacy Bridge plan must obtain both prescriber attestation and pharmacy alignment verification. [SECTION] - **Tier 3 (Non-Preferred & Specialty Entry):** May require dual-layer review if member has not met chronic condition enrollment criteria (CCE) in the last benefit year. Tier migration possible mid-cycle based on new formulary rules. [SECTION] - **Tier 4 (Specialty Injectables, Biologics, and Condition-Limited Agents):** Includes drugs subject to clinical pathway alignment; claims must be adjudicated through the PBM’s split-fulfillment logic unless the prescribing entity is credentialed as Tier 4-A. [SECTION] 🚫 Exception: Certain biosimilars classified under Tier 4 in national formularies may be covered at Tier 2 if dispensed under limited-distribution contracts, provided the prescribing facility participates in the 340B program **and** the member is flagged under Enhanced Affordability Priority (EAP). [SECTION] 🔁 **Prior Authorization (PA) Layering Logic** [SECTION] Drugs requiring PA are subject to a three-stage filter: [SECTION] 1. **Therapeutic Criteria Review (TCR)** – Clinical alignment with diagnosis and formulary path. [SECTION] 2. **Coverage Policy Sync (CPS)** – Matches requested use with plan sponsor coverage schema. [SECTION] 3. **Utilization Watch Flag (UWF)** – If triggered, a third-party medical director review is initiated (adds 2–4 business days). [SECTION] 💡 Exemplar: *Trulicity* (GLP-1 receptor agonist) [SECTION] - **Base Tier:** Tier 3 across most commercial plans [SECTION] - **Override Possibility:** Auto-lifts to Tier 2 under Metabolic Risk Bundling if member is concurrently enrolled in cardiac risk management AND insulin titration modules. [SECTION] - **Caveat:** Auto-injector version may still trigger UWF if prescribed without 90-day adherence documentation to metformin or contraindication to semaglutide. [SECTION] 🗂️ **Adjudication Complexity Notes** [SECTION] - Fill attempts at non-network or out-of-state pharmacies may default to full retail pricing, even if coverage is active. [SECTION] - Certain maintenance tier drugs can only be filled at 90-day intervals after two successful 30-day fills unless dispensed via SmartSync (auto-align refill system). [SECTION] - Claims using discount cards (e.g., manufacturer copay assistance) will not count toward deductible or out-of-pocket limits unless the pharmacy submits a Coordinated Adjudication Adjustment Request (CAAR). [SECTION] ⚠️ **Denials & Appeals** [SECTION] - If PA is denied, appeals must cite new clinical rationale. Re-submission of identical documentation will be auto-denied. [SECTION] - Members in Tier Restructuring Delay (TRD) periods due to employer override cannot file external appeals unless the drug is life-sustaining and not replaceable under Tier 1/2. [SECTION] - Denials on non-formulary drugs are not eligible for Tier Transition Program (TTP) unless covered during prior plan year with no lapse in coverage >30 days. [SECTION] 📊 **Plan Differences** [SECTION] - Standard, Enhanced, Platinum, and Concierge tiers each have different deductible-accumulation thresholds and copay structures. [SECTION] - For Platinum+ plans, Tier 3 copay is waived on first-time fills initiated post-discharge from an inpatient episode if coded using post-acute NDCs. [SECTION] 📣 Misc. Clarifications [SECTION] - The “Healthy Living Rewards” program, mentioned in new member packets, does not affect coverage or drug tier placement. It is a wellness initiative only. [SECTION] - Benefit year resets on Jan 1, but tier realignment occurs quarterly and may retroactively affect claims filled in the trailing 45-day buffer period. [SECTION] 🔒 REMINDER: Member Services guidance may reflect outdated tier assignments if formulary refreshes are in progress. Online lookup tools update in real time and take precedence during adjudication disputes."
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