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Special Requirements and Limitations for Certain Medications

Requirements for Specialty Medications

Specialty medications include those used in the treatment of complex medical conditions. Examples include hepatitis C, hemophilia, multiple sclerosis and rheumatoid arthritis.

Through Accredo® you can have covered self-administered specialty drugs delivered directly to you or your doctor's office.*

View the Specialty Pharmacy Program Drug List which includes a reminder about coverage for self-administered specialty medications.

To order through Accredo:

  • For new prescriptions — Ask your doctor to call in your prescription to 1-833-721-1619 or e-prescribe your prescription to Accredo. Your doctor can find e-prescribing information at this website.
  • For existing prescriptions — You can request a transfer of your existing prescription for a specialty medication by calling 1-833-721-1619.

*A specialty pharmacy coordinator will contact you to confirm you correct mailing address and arrange delivery of your covered medications.

Accredo® is a specialty pharmacy that is contracted to provide services to members of Blue Cross and Blue Shield of Illinois. Accredo is a trademark of Express Scripts Strategic Development, Inc.

Requirements for Generic Medication

Some brand-name drugs are also available in a generic version. If your medication is available in a generic equivalent version with the same active ingredients and at the same dosage you will pay more if you choose to buy the brand-name version. In that case, you will pay your higher copayment or coinsurance amount, plus the difference in cost between the brand drug and its generic equivalent. When you can, buying the generic version may save you money.

Learn more about generic drugs

Requirements for Over-the-Counter (OTC) Medications

Keep in mind medications that can also be found over-the-counter (OTC) are usually not covered through your prescription drug plan, even if your doctor has prescribed it. Because these drugs are not covered under your plan, buying the OTC version can often save you money.

To see if a specific drug may have an OTC version, view the over-the-counter equivalent exclusion program drug list

Dispensing Limits for Certain Medications

To help promote safe drug usage, there are coverage rules put on certain medications. These rules affect:

  • The amount of medication covered per prescription
  • The amount of medication covered in a given time period

These limits reflect generally accepted pharmaceutical manufacturers' guidelines and help encourage medication use as intended by the U.S. Food and Drug Administration (FDA).

For more information, view the dispensing limits included in the Performance Drug List.

Appropriate Use of Opioids Program

This program uses point-of-sale safety checks. These checks are backed by guidelines from the Centers for Disease Control and Prevention (CDC) and others. The goal is to help members take prescription opioids safely.

One point-of-sale safety check is to review a member’s daily morphine equivalent dose (known as MED). If you take a dose each day long-term (or more than 30 days in a row), here is what you need to know:

  • More than 120 mg – 200 mg MED: You have a higher chance of opioid-linked dangers like overdose and death than those who take less than that amount.
  • More than 200 mg MED: You may need to meet certain safety criteria to have coverage under your plan.

Members should also be aware that some opioid prescriptions may have a shorter refill window. This means you may need to wait until you have used almost 90% of your meds (based on dosing orders from your doctor) before you can get your refill.

Please call us at 1-877-217-7986 if you have any questions. Your doctor can find program request forms at www.bcbsil.com/provider.