Understanding Your Prescription Drug Coverage

A formulary is a list of prescription drugs covered by your Blue Cross Community Health Plan. Our formulary is developed and reviewed by a team of doctors and pharmacists to ensure members have access to safe, effective, and affordable medications.

Important Note: Our formulary is updated regularly. Always check the most current formulary to confirm coverage for your medications.

How the Formulary Works

The Blue Cross Community Health Plans formulary includes both brand-name and generic medications. Generic medications typically cost less than brand-name drugs and have the same active ingredients, strength, and dosage form as their brand-name counterparts.

Our formulary is organized into tiers based on cost-sharing amounts. Medications are placed in tiers according to their clinical effectiveness and cost relative to other drugs that treat the same condition.

Drug Tier System

Tier 1: Generic Drugs

Lowest cost share for preferred generic medications. These drugs have been tested and approved by the FDA as safe and effective alternatives to brand-name drugs.

Tier 2: Preferred Brand

Medium cost share for preferred brand-name medications. These are brand-name drugs that offer unique value or where generic alternatives are not available.

Tier 3: Non-Preferred Brand

Higher cost share for non-preferred brand-name medications. These are brand-name drugs where equally effective lower-cost alternatives are available.

Tier 4: Specialty Drugs

Highest cost share for specialty medications. These are typically high-cost drugs used to treat complex, chronic conditions.

Medication Categories Covered

Our formulary covers medications across a wide range of therapeutic classes including:

  • Cardiovascular medications (blood pressure, cholesterol, heart medications)
  • Mental health medications (antidepressants, antipsychotics, anti-anxiety)
  • Diabetes management supplies and medications
  • Respiratory medications (asthma inhalers, COPD medications)
  • Pain management medications
  • Antibiotics and anti-infectives
  • Dermatology preparations
  • Gastrointestinal medications
  • Allergy and immunology medications

Prior Authorization

Certain medications on our formulary require prior authorization before they can be covered. This means you must get approval from Blue Cross Community Health Plans before filling the prescription. Your healthcare provider can help initiate this process.

Prior authorization helps ensure safe and appropriate use of medications and can help control costs for both you and the plan. The process typically involves your provider submitting clinical information about why you need the specific medication.

Step Therapy

For some medications, step therapy may be required. This means you may need to try a lower-cost or preferred medication first before the plan will cover a higher-cost alternative. If you've already tried the required medication(s) and it was ineffective, your provider can request an exception.

Quantity Limits

To ensure safe and appropriate use, some medications have quantity limits, which restrict the amount you can receive within a certain time period. For example, you may be limited to 30 tablets per month for a particular medication that is typically taken once daily.

Requesting a Drug Exception

If medication you need is not on the formulary or has restrictions, you can request an exception. There are several types of exceptions:

  • Formulary Exception: Request to cover a non-formulary drug
  • Tiering Exception: Request to lower the tier of a covered drug
  • Prior Authorization Exception: Request to waive prior authorization requirements
  • Step Therapy Exception: Request to waive step therapy requirements
  • Quantity Limit Exception: Request to exceed quantity limits

To request an exception, you or your prescriber should contact Member Services. You may need to provide supporting documentation from your prescriber explaining why the requested drug is medically necessary.

Exception Type Processing Time Expedited Review Criteria
Standard Exception Generally within 72 hours Not applicable
Expedited Exception Within 24 hours Standard refilling timeframe would jeopardize your health or ability to attain maximum functioning

Appeals Process

If your request for an exception is denied, you have the right to appeal the decision. You must file your appeal within 60 days of receiving the denial notice. If your health condition requires a quicker decision, you can request an expedited appeal, which will be decided within 72 hours.

Formulary Updates

Our Pharmacy and Therapeutics Committee reviews the formulary regularly. Changes may involve:

  • Adding new drugs
  • Removing drugs
  • Moving drugs to different tiers
  • Adding or removing prior authorization or step therapy requirements
  • Changing quantity limits

When changes are made to the formulary, we will provide at least 60 days advance notice to affected members. However, if the FDA determines a drug to be unsafe, or if a drug is removed from the market, we may remove the drug from our formulary immediately.

Formulary Resources

Blue Cross Community Health Plans provides several resources to help you understand your prescription drug coverage:

  • Online Formulary Search: Search our complete formulary on our website
  • Member Services: Call our helpline for assistance with your prescription benefits
  • Pharmacist Assistance: Your pharmacist can help identify lower-cost alternatives
  • Clinical Pharmacy Program: Available for members with complex medication needs

Tips for Maximizing Your Prescription Benefits

  • Choose generic medications when available
  • Use preferred brand-name drugs over non-preferred alternatives
  • Check if prior authorization requirements apply before visiting the pharmacy
  • Consider 90-day supplies through our mail order pharmacy program
  • Review the formulary annually for changes that may affect your medications

Using Preferred Pharmacies

Blue Cross Community Health Plans contracts with preferred pharmacies to offer you the best value for your prescription medications. Using a preferred pharmacy can help you save money through:

  • Lower copays and coinsurance
  • Additional discounts on selected medications
  • Enhanced clinical services

Specialty Medications

Specialty medications are typically used to treat complex, chronic conditions and may require special handling, administration, or monitoring. These medications are available through our specialty pharmacy partners, who provide:

  • Expert clinical support and education
  • Flexible delivery options
  • Assistance with insurance coverage
  • Coordination with your healthcare providers

Conclusion

Understanding your Blue Cross Community Health Plans formulary can help you make informed decisions about your prescription medications and manage your healthcare costs effectively. Our goal is to provide you with access to safe, effective, and affordable medications while ensuring you receive appropriate healthcare.

If you have questions about your prescription coverage or the formulary, please contact Member Services using the information on your member ID card. Our representatives are available to assist you with your prescription benefits and help you understand how to make the most of your pharmacy coverage.