Prescription Drug Information for HMO Members

A formulary is a list of preferred drugs considered to be safe and cost-effective. Your prescription drug benefits through Blue Cross and Blue Shield of Illinois may be based on either the standard formulary or the generics plus formulary. If so, how much you pay out-of-pocket for prescription drugs is determined by whether your medication is on this list. The drugs on this list are chosen based on many factors, including safety, effectiveness and cost.

View the 2012 Standard Formulary .

View the 2012 Generics Plus Formulary .

• Please consider talking to your doctor about prescribing these medications, which may help reduce your out-of-pocket costs.
• The list may help guide you and your doctor in selecting an appropriate medication for you.
• The list is frequently updated to reflect new drugs and other changes in the market. View the 2012 Standard Formulary Updates list .
• We have also put together a list of commonly prescribed formulary medications. View the 2012 Commonly Prescribed Standard Formulary Medications list .

Note that some medication classes (for example, fertility) may be excluded by some plans, meaning they are not covered. See your benefit plan booklet for details.

• Your prescription drug coverage includes limits on certain medications.
• Limits may include quantity of covered medication per prescription, quantity of covered medication in a given time period and coverage only for members within a certain age range.
• These limits reflect generally accepted pharmaceutical manufacturers’ guidelines.
• They also help encourage medication use as intended by the U.S. Food and Drug Administration (FDA).
• For more information, view the 2012 Standard Formulary Drug Dispensing Limits list . Dispensing limits for the Generics Plus Formulary are included in the document posted above.

Medications with an equivalent available over-the-counter (OTC) are usually not covered through Blue Cross and Blue Shield of Illinois prescription drug plans.

Some facts to consider:

• You will not usually receive coverage for brand and generic prescription medications that have OTC versions available at the same prescription strength.
• You may still purchase the medication–either by prescription or over-the-counter – but you will be responsible for the full cost of the drug.
• Choosing to purchase the OTC version will often save you money.
• To see if a specific drug is part of the program, view the over-the-counter equivalent exclusion program drug list 
• If you have questions about the program, call the Pharmacy Program number on the back of your ID card.
• Talk with your doctor before making any changes to your current medication regimen. As always, treatment decisions are between you and you doctor.

This program does not apply to members who have outpatient prescription drug coverage through their medical plan, processed by BlueSCRIPT^SM.

The 90-day supply benefit program can save you both time and money. With this program, you have the option of obtaining up to a 90-day supply of maintenance medications through a network of contracting retail and mail service pharmacies. Maintenance medications are those drugs you may take on an ongoing basis to treat conditions such as high cholesterol, high blood pressure or diabetes.

Some things to consider:

• Your specific benefit plan and medication will determine the amount you pay.
• Using a generic or formulary brand medication may save you money.

How to Obtain Maintenance Medication at a Retail Pharmacy

• First, locate a contracting 90-day supply retail pharmacy  within the state of Illinois.
• Ask your doctor to write you a new prescription for up to a 90-day supply with three refills, depending on your situation.

How to Obtain a Maintenance Medication from a Mail Service Pharmacy

Current contracting 90-day supply mail service pharmacies include PrimeMail^® and Walgreens Mail Service. Follow these steps if you are ordering maintenance medications through either of these services for the first time:

• Your doctor may write your prescription for up to a 90-day supply with three refills, depending on your situation.
• If you need the medication right away, ask your doctor to also give you a prescription for up to a 34-day supply to fill immediately at a local contracting pharmacy.
• Send the prescription(s), the applicable registration and prescription order form and the full amount you owe (credit card or check only) to the address on the order form.

Ordering Through PrimeMail

• View and download the PrimeMail registration and order form .
• If you are already registered with PrimeMail, you may also give this PrimeMail physician fax form  to your doctor to send directly.
• PrimeMail will only accept the faxed prescription directly from your doctor’s office.
• When you log in to Blue Access for Members and visit your Rx Drugs page, you can also ask that PrimeMail get in touch with your doctor to request a new prescription.

For more information, download the PrimeMail flier .

Ordering Through Walgreens Mail Service

• View and download the Walgreens Mail Service registration and order form .
• If you are already registered with Walgreens Mail Service, you may also give this Walgreens Mail Service physician fax form  to your doctor to send directly.
• Walgreens Mail Service will only accept the faxed prescription directly from your doctor’s office.

For more information, download the Walgreens Mail Service brochure .

If you have questions about the 90-day supply program, call the Pharmacy Program number on the back of your ID card.

The prior authorization/step therapy program is designed to encourage safe, cost-effective medication use. Most HMO groups include this program.

Prior Authorization

Under this part of the program, your physician will be required to obtain authorization through Blue Cross and Blue Shield of Illinois in order for you to receive benefits for certain medications and drug categories.

• Below are drug categories and specific medications for which a prior authorization program exists for most HMO members.
• Please note that drug categories may be added and the medications listed are only examples. Call the Pharmacy Program number on the back of your ID card with questions about a specific medication.
• As always, cost is only one factor in choosing medication and treatment decisions are between you and your doctor.

* Third-party brand names are the property of their respective owners.

** Included in the program as of 4/1/12.

More information is available in the prior authorization member flier .

Step Therapy

The step therapy program requires that you have 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.

Step 1: When possible, your doctor should prescribe a first-line medication appropriate for your condition.

Step 2: If your doctor determines that a first-line drug is not appropriate for you or is not effective in treating your condition, your prescription drug benefit will cover a second-line drug when certain criteria are met.

• Below are drug categories and specific medications for which a step therapy program exists for most HMO members.
• Step therapy does not apply to the generic equivalents for these medications (if available), so if you and your doctor decide the generic equivalent is best for you, prior authorization is not required.
• These medications are listed along with the first use approved by the U.S. Food and Drug Administration, but may be prescribed for conditions other than those noted and would still be part of the step therapy program.
• Please note that drug categories may be added and the medications listed are only examples. Call the Pharmacy Program number on the back of your ID card with questions about a specific medication.
• As always, cost is only one factor in choosing medication and treatment decisions are between you and your doctor.

* Third-party brand names are the property of their respective owners.

** Included in the program as of 4/1/12.

More information is available in the step therapy member flier .

If you have questions about the prior authorization/step therapy program, call the Pharmacy Program number on the back of your ID card.

Below are some commonly prescribed brand medications and their generic equivalents. This sample list is for reference only. It does not represent a complete list of drugs covered under your plan and is not intended to be a substitute for your physician's clinical knowledge and judgment. Remember, treatment decisions are always between you and your doctor.

What is a formulary?

Can I use non-formulary drugs?

Can a mail service pharmacy receive fax prescriptions?

How much will I pay at the pharmacy?

Who do I contact if I have questions?

What is a formulary?

The Blue Cross and Blue Shield of Illinois prescription drug formulary is a list of preferred drugs selected by a panel of physicians and pharmacists. The formulary includes all generic drugs and a select group of brand drugs. All drugs are evaluated on their comparative efficacy, safety, uniqueness and cost-effectiveness. The formulary is revised on a regular basis to reflect the availability of new prescription drugs and other changes in the market.

top of page

Can I use non-formulary drugs?

Yes. Blue Cross and Blue Shield of Illinois uses an open prescription drug formulary, which means you have benefit coverage for most drugs, even if they are not on the formulary. You will, however, pay the highest copayment or coinsurance amount for non-formulary drugs.

top of page

Can a mail service pharmacy receive faxed prescriptions?

Yes, if a change is made to an existing prescription and you need a refill immediately, you can provide your doctor with a physician fax form so that he/she can send your prescription directly to the mail service pharmacy for you. Please note that the mail service pharmacy will only accept a fax prescription that is sent directly from your doctor's office. Prescriptions faxed for controlled substances will not be processed. You must mail the original prescription signed by your doctor to the mail service pharmacy.

top of page

How much will I pay at the pharmacy?

If your benefit plan is based on a three-tier design, your copayment or coinsurance amount will be lowest for generic medications, the same or higher for brand drugs that are on the formulary, and highest for brand drugs that are not on the formulary.

top of page

Who do I contact if I have questions?

As always, you should discuss questions and concerns about drugs that you are taking with your doctor. He or she can discuss whether a formulary medication is appropriate for you. If you have any questions about your prescription drug benefits, call the Pharmacy Program at (800) 423-1973.

top of page