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Pharmacy Plan FAQs

Questions about the Preferred Drug List/Formulary

What is a formulary (preferred drug list)?

The BlueCross BlueShield of Tennessee prescription drug formulary is a list of preferred drugs selected by a panel of physicians and pharmacists. These preferred drugs include both generic (Tier 1) and preferred brand name (Tier 2) drugs. Non-preferred brand name (Tier 3) drugs are not part of the preferred drug list, but are covered by your pharmacy benefits.

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.

Your prescription drug benefits through BlueCross may be based on either the standard formulary or the limited 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.

What is a 3-Tier Prescription Drug plan?

All covered prescriptions drugs fall into one of three categories or tiers. Each tier represents the level of cost that you will pay for that particular drug. When a new drug is considered for formulary placement, an attempt is made to examine the drugs relative to similar drugs currently on the formulary. Each therapeutic group is designated by disease state or drug class. Drug lists are a part of each therapeutic group. They show an assigned copay tier for each drug, reflecting the level of member share of the prescription cost. The BlueCross Three Tier Formulary is separated into the following categories:

  • Generic (Tier 1): Generic drugs offer the lowest member copayment and this tier includes all generics, even those not listed. These drugs are made with the same active ingredients and in the same dosage form as the brand name product. Generics must meet the same FDA standards as brand drugs and provide the same therapeutic effects. These drugs are labeled with the manufacturer’s chemical name and often have a brand name equivalent.

     

  • Preferred Drugs (Tier 2): This tier includes selected branded products that are more cost-effective than similar drugs within a common drug class. A portion of the savings is passed to our members by a reduced member copayment.

     

  • Non-Preferred Drugs (Tier 3): You or your doctor may decide a medication in this category is best suited for your needs. This tier includes brand name medications not selected for Tier Two and all branded products not mentioned within the formulary. In most cases, there is an equally reasonable alternative drug one of the other tiers for the products listed in this category that is equally effective and less costly. Standard member copayment will apply.

What types of drugs are on the preferred drug list?

The BlueCross preferred drug list includes:

  • Most Food & Drug Administration (FDA) approved generic drugs (Tier 1) and
  • Selected FDA-approved brand name drugs (Tier 2).

Note: The list is subject to change and is periodically updated

How can I find out if my drug is on the preferred drug list?

  • Review the preferred drug list
  • Call Customer Service at the number on your member ID card.

My drug was on the Preferred Drug List last year, but now it's not. Why?

We have a committee that meets regularly to review new drugs and information about drugs that are on the market.  Drugs can be added to or removed from the Preferred Drug List at any time:

  • As brand-name medications lose patents and generic versions become available, the brand-name medication may be covered at a higher copayment while the generic medication may be covered at a lower copayment.
  • The FDA approves many new medications throughout the year.
  • Medications can be withdrawn from the market or may become available without a prescription. Over-the-counter (OTC) drugs are not generally covered under a prescription plan.

We might also move a drug from one coverage tier to another.

Why isn't the drug I take covered?

There are several reasons why a medication may not be covered:

  • It is experimental or new.
  • Your doctor prescribed the medication for a use not recognized by the FDA or other professional medical organizations.
  • It was dispensed in your doctor's office (example: a vaccine). Drugs dispensed in a doctor's office are not covered under your pharmacy benefits; your medical benefits may provide coverage.
  • Your prescribed medication requires step therapy.
  • There are equivalent over-the-counter medications available.
  • Your employer does not offer all benefits available through your pharmacy plan. For example, pharmacy benefit plans may cover injectable fertility medications for one pharmacy plan member but not for another based on the plan chosen by the employer.
  • Research indicates that the drug is not safe for some people.

Learn more about why your pharmacy benefits plan may not cover a drug by calling the number on your member ID card. You can buy any drug your doctor prescribes, even if it is not covered by your plan; you will have to pay the full cost of the drug.  If you are BlueCross pharmacy member and are denied coverage for a medication, talk to your doctor. He/she can advise you on the best steps to take.

How do I find out if I can take another drug in place of one that's not covered?

Talk to your doctor about alternatives. To see if an alternative drug is covered:

  • Review the preferred drug list
  • Call Customer Service at the number on your member ID card.

How can I get a drug added to the Preferred Drug List?

BlueCross’ Pharmacy Management regularly reviews drugs to determine what should be on the Preferred Drug List. Your physician may write to us to request that a drug be added to the list. Your physician should provide copies of peer reviewed medical literature to validate the superiority of the medication requested to be added to the Preferred Drug List.  A committee will review and consider the request.

What are Preventive Medications? How does BlueCross choose which drugs are considered Preventive Medications on the High

Preventive medications are generally prescribed for people who may be at risk for certain diseases or conditions but who are not yet showing signs. Preventive care does not include drugs or medicines for treatment of an existing illness or condition. Preventive medications are used to prevent:

  • a disease or condition;
  • complications from a disease; or
  • reoccurrence of a condition.

We selected drug classes that are largely used for preventive purposes and are associated with several highly common conditions. People with these conditions can be symptom-free if the condition is managed well; failure to manage these conditions can result in serious illness or injury.

The Preventive list reflects guidance provided by the U.S. Department of Treasury indicating that certain drugs could be covered as preventive for selected conditions under a High-Deductible Health Plan (HDHP).  The drugs were selected based on Federal guidance and according to clinical and pharmacoeconomic criteria, including: relative high-prevalence of the diseases underlying the use of the drugs, clinical indication, as well as therapy class effectiveness towards preventing an illness or a reoccurrence of an illness

Questions about Brand and Generic Drugs

What are generic drugs? Do I have to use a generic drug if it is available?

Generic drugs are identical, or "bioequivalent" to brand-name drugs - in dosage, safety, strength, route of administration, quality, performance characteristics and intended use. Although generic drugs are chemically the same as their branded counterparts, they are typically sold at substantial discounts from the branded price.

Remember: You will pay less for generic drugs almost every time. Under most BlueCross plans, if a generic drug is available and you purchase a brand name drug, you will pay the generic (Tier 1) copay PLUS the cost difference between the brand-name and the generic equivalent. Check your Evidence of Coverage to see if this applies to your plan.

What is the difference between generic and brand-name drugs and how does my plan treat them differently?

Generic and brand name drugs have the same active ingredients, in the same dose and form. Inactive ingredients may vary.

The significant difference between them is the price. Brand-name drugs are more expensive. In fact, the use of generics is a valuable way to reduce overall prescription drug costs without sacrificing quality.

Generic drugs make economic sense for BlueCross members because under most of our plans they have a lower copayment. Depending on your plan design, you get a therapeutically equivalent drug for less money.

Why are brand-name drugs more expensive?

Brand-name drugs are generally more expensive than generics because drug makers invest money to support the research, development and marketing of each new medication. They look to recover some of these costs with higher pricing. Because there are no pricing controls, manufacturers can set their own prices on patent-protected drugs.

When a patent expires on a brand-name drug, generic manufacturers can produce a generic version. Because generic drug makers are not introducing a new drug, they avoid the expenses of developing it. This is reflected in the lower price.

Are all available generic drugs included as Tier 1 drugs on the preferred drug list?

Most generic drugs that have Food & Drug Administration (FDA) approval are included in Tier 1 of the preferred drug list.

Exceptions:

  • Those not approved by the FDA
  • Those used for cosmetic purposes
  • DESI drugs (drugs designated not effective by the FDA)
  • Most over-the-counter (OTC) drugs
  • Those excluded by your employer's benefit plan

What is the difference between a preferred brand name drug (Tier 2) and a non-preferred brand name (Tier 3) drug?

Preferred (Tier 2) drugs are brand name drugs which are:

  • Chosen for their quality and affordability
  • Not available as a generic drug
  • Indicated through research to be as effective as non-preferred (Tier 3) drugs

Non-preferred (Tier 3) drugs are brand name drugs which are:

  • Typically more expensive
  • Covered at the highest copay

Questions about Plan Requirements

What is Prior Authorization?

The drugs on the prior authorization list need authorization from your benefit plan before they are dispensed by your pharmacy to ensure that the patient meets medical criteria. Your network physician is responsible for contacting the Pharmacy Benefit Manager to obtain prior authorization when prescribing a drug on this list. Ask your physician to make the call at the same time the medication is prescribed so that there will be no delay when you go to the pharmacy.

How does Prior Authorization work?

Your doctor should call the Pharmacy Benefit Manager PRIOR to writing a prescription for any drug on the Prior Authorization list.

Without proper authorization, you will pay the full price of the prescription rather than only your copay.

Does my doctor need to get a Prior Authorization each time my prescription is filled?

No. Once a Prior Authorization is given, it is typically valid for six (6) months to a year.

What can I do if I am at the pharmacy and discover my medication requires a Prior Authorization but none was requested i

Have your pharmacist call your doctor to start the Prior Authorization process. The request will be approved or denied within 72 hours after the physician provides information.

What is step therapy?

Step therapy is a clinical program that only applies to certain types of prescription medications. With step therapy, you will receive benefits for drugs subject to step therapy only after first trying an alternative medication which has been determined to be safe, effective and less costly. In cases where alternative drugs are not appropriate for you to use, your physician can request an exception to the step therapy program.

Why does the drug formulary include step therapy?

Step therapy programs help manage the rising cost of prescription drugs, and the overall cost of health care. A “step” approach encourages the safe, cost-effective use of medication by first trying lower-cost medications whenever appropriate.

How does step therapy work?

  • You present a prescription for a drug requiring step therapy at the pharmacy.
  • The pharmacist enters the prescription information into the claim system.
  • The claim is submitted for processing – the claims system automatically looks back at your claims history (generally 180 days) to see if you have had a prescription filled in that time period for the alternative drug.
  • If a claim for an alternative drug is found, the claim for the drug requiring step therapy will automatically process.
  • If there is no history of a prescription filled for an alternative drug in the past 180 days, the prescription claim is rejected.
  • The pharmacist can either contact your physician to see if an alternative drug is acceptable or will advise you to contact your physician.
  • The physician can then provide a prescription for an alternative drug. If the physician strongly feels that the original drug prescribed will best treat the your condition, then the physician can submit a step therapy authorization request. If the request meets pre-specified clinical criteria, the originally prescribed drug will be covered.
  • A notification will be sent to both you and your physician on whether the request has been approved or denied. The review takes approximately five to ten business days.

What are quantity limits?

Some drugs have a limit on how many doses you can get. You may need approval first if your doctor prescribes more than what is recommended. These limits are in keeping with the manufacturer’s and the U.S. Food and Drug Administration’s (FDA) recommendations and accepted medical practices. This applies to drugs that:

  • Are often taken in the wrong way
  • Are often taken in amounts greater than the recommended dose

How does the Quantity Limits component work?

Physicians who write prescriptions that exceed the Quantity Limit must call the Pharmacy Benefits Manger to request a Prior Authorization before the prescription can be filled at the levels that exceed the drug's Quantity Limit.

Questions about Pharmacy Network & Coverage

How do I know which pharmacies in my area participate in the BlueCross network?

Network pharmacies fill your prescriptions and file the claims for you, making the process quicker and easier. Visit our Find-A-Doc Tool to search our network for participating pharmacies near you.

Why should I use a participating (in-network) pharmacy?

You receive maximum benefits (and processing convenience) when using a participating pharmacy.

What if I obtain a prescription medication from a non-participating (out-of-network) pharmacy?

When you use a pharmacy that is not in the BlueCross network, you pay the full amount at the time of purchase and submit a claim for reimbursement -- less your applicable copay or coinsurance amounts (subject to limitations and restrictions). Reimbursement is based on the BlueCross BlueShield of Tennessee allowed charge, less any applicable copay, deductible or coinsurance amount. Refer to your Evidence of Coverage or member handbook for details.

How do I get prescriptions outside of the U.S.?

Prescription medication purchased, via the Internet, outside the U.S. and it’s territories are excluded for reimbursement and is considered ineligible per the benefit policy. Current laws do not allow citizens to import prescription drugs from foreign countries. BlueCross defines covered prescription drugs as those approved for use by the Food and Drug Administration (FDA). Prescription medications purchased outside the U.S. bypass the controlled distribution system. The FDA cannot assure that medications purchased in other countries conform to the manufacturing and quality assurance procedures mandated by U.S. laws and regulations.

In situations where you are traveling or residing outside of the U.S. and a prescription medication is necessary, benefits will be considered for this service. You will pay for the prescription medication out-of-pocket and then submit the receipts to BlueCross in order to be processed for possible reimbursement, subject to the terms of the plan benefits.

How do I get a vacation override when traveling?

Members going on vacation, etc. may sometimes need an early refill. Your pharmacy may call the PBM and obtain the early override for up to a one month supply per member per year. Please fax any refill request made for greater than a one month supply to Pharmacy Appeals for review and approval. (i.e. – member leaving the country for 3-6 months).

How do I get a lost prescription replaced?

If you report medication has been lost and need an early refill, you or your physician can submit a request for a refill override. This request can be faxed to 1-888-343-4232 or 423-535-5100, making sure to include the following information: patient's name, patient's ID number and medication(s) requested.

How do I get a stolen prescription replaced?

If you report a prescription medication has been stolen and need an early refill, information will be needed in order to be reviewed for approval by the Pharmacy Management area.

  • Controlled Substance, i.e. Narcotics - If the medication stolen is a controlled substance such as Oxycodone, Hydrocodone, Ambien, etc. you will have to submit a police report along with the request for an early refill. You or your physician can submit a request for the refill override. This request can be faxed to 1-888-343-4232 or 423-535-5100, making sure to include the following information: patient's name, patient's ID number, medication(s) requested and police report (if medication is a controlled substance).
  • Non Controlled Substance - Same procedure as above for Controlled Substance, but you do not have to submit a police report.

How are specialty drugs covered?

Specialty drugs are categorized as either provider-administered or self-administered. Provider-administered specialty drugs are usually given by injection or infusion by the physician or other health care provider. Provider administered drugs are covered as a medical benefit, and in most plans are subject to the specialty pharmacy copay or deductible/coinsurance for those plans that do not have copays.

Self-administered drugs are drugs that the patient administers to themselves, usually by injection. Self-administered specialty drugs are covered as a prescription drug benefit. Members are encouraged to obtain self-administered specialty drugs from the specialty pharmacy network, but can also purchase from any retail network pharmacy. The copay will be higher when not using the specialty pharmacy network. NOTE: Members without prescription drug coverage with BlueCross do not have coverage for self-administered specialty drugs under your BlueCross medical insurance plan.

For more information about our specialty pharmacy program and preferred specialty pharmacy vendors, please visit our Specialty Medications Program page.

How are compound drugs covered?

Compound Drugs are only covered when filled at a participating compound pharmacy. If you fill a prescription for a compound drug at a pharmacy that is not participating for compound drugs, you will have to pay out-of-your pocket for the medication and will not be reimbursed from the plan. To find a participating compound pharmacy, visit our Find-A-Doc Tool to search our network for participating compound pharmacies near you.

Questions about Home Delivery

What is Mail Order?

Mail Order is easy and convenient. You can have your prescriptions delivered right to your home with the Home Delivery Mail Order Service from BlueCross. With this service, you can:

  • Purchase up to a three-month supply of your medicine at once
  • Enjoy convenient delivery to the address of your choice
  • Enjoy free standard shipping of your orders
  • Talk with a registered pharmacist, 24 hours a day, seven days a week
  • Order refills anytime online or by phone

How do I get my prescriptions filled through a mail order pharmacy?

BlueCross BlueShield of Tennessee offers convenient ways to receive up to 90-day supply of prescriptions medications covered by your pharmacy benefit plan. To learn more about our home delivery prescription program by, visit How to Mail Order Your Drugs page.

  • Ask your doctor for two prescriptions: one for a short-term supply (for instance, 30 days) to fill at a participating retail pharmacy, and one for a three-month supply with any allowed refills
  • Take the medicine for two weeks before sending the prescription for the larger supply to the mail order pharmacy. Your doctor may want to monitor your initial reaction and response to the medicine.

To refill a prescription, choose one of the three easy ways described below. Be sure to have your member ID card and prescription number from a current mail order label or refill slip.

Online

  • Visit bcbst.com and log into BlueAccess, your secure online member portal. Follow the instructions for refilling your prescriptions.

By Telephone

  • Call mail order Member Service at 1-877-673-9165.
  • Use the automated phone system to request your prescription refill. If you need help, you will be transferred to a Member Services representative.

By Mail

  • Complete the mail order prescription form. You can pay by e-check, check, money order or credit card. Make checks and money orders payable to Express Scripts and write your BlueCross BlueShield of Tennessee member ID on the front.

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