Prescription Drug Benefits
Find out what medications are covered and where you can get your prescriptions filled to maximize your benefits.
Check these documents and your Benefits Certificate to see if your prescription drugs are covered. The prescription drug list (also known as a formulary) consists of mostly preferred generic and many brand-name medications. Choosing drugs from this list may save you money.
If you don't see your medication on the list check with your doctor for a generic or lower-cost option on the drug list that may work just as well and may save you money.
Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. Your plan may have a different coverage level for specialty drugs. If you have questions about your coverage for specialty medications or your prescription drug benefit, call 877.217.7986 to talk to a Customer Advocate.
Medications That Must be Preapproved
Under the Prior Authorization Program, your doctor has to get approval from Blue Cross and Blue Shield before your prescription drug plan will cover certain medications and drug categories.
Medications That Require a Prescription History
The Step Therapy Program encourages safe, cost-effective medication use by requiring you to have a prescription history for a "first-line" medication before your benefit plan will cover a "second-line" drug.
- A first-line drug is recognized as safe and effective in treating a specific medical condition, as well as being a cost-effective treatment option.
- A second-line drug is a less-preferred or potentially more costly treatment option.
If you are a current member and have recently gone through the Step Therapy Program, you do not have to complete it again.
Where to Fill Your Prescription
To use your prescription drug benefits:
- Find a contracting pharmacy near you and show them your member ID card.
- For maintenance medications, you can have up to a 90-day supply sent right to your home. Your plan may also allow you to fill a 90-day supply of your covered maintenance medication(s) at a contracting pharmacy. Be sure to check your benefit materials to verify.
Log in to Blue Access for MembersSM to find the prescription drug forms that specifically apply to your coverage under the "Forms and Documents" tab.
Other Special Requirements and Limitations
Certain medications have special rules for coverage which may include:
- Higher out-of-pocket costs for name-brand drugs that have generic or over-the-counter versions
- Requirements around specialty medications used to treat complex medical conditions such as Hepatitis C and multiple sclerosis (MS)
- Restrictions on how much of a drug you can get at once and how often you can get that prescription refilled at that quantity