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.
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:
The BlueCross preferred drug list includes:
Note: The list is subject to change and is periodically updated
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:
We might also move a drug from one coverage tier to another.
There are several reasons why a medication may not be covered:
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.
Talk to your doctor about alternatives. To see if an alternative drug is covered:
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.
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:
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
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.
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.
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.
Most generic drugs that have Food & Drug Administration (FDA) approval are included in Tier 1 of the preferred drug list.
Preferred (Tier 2) drugs are brand name drugs which are:
Non-preferred (Tier 3) drugs are brand name drugs which are:
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.
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.
No. Once a Prior Authorization is given, it is typically valid for six (6) months to a year.
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.
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.
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?
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:
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.
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.
You receive maximum benefits (and processing convenience) when using a participating 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.
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.
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).
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.
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.
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.
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.
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:
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.
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.
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In Tennessee, 55% of those using prescription pain pills inappropriately get them from family and friends. Prevent abuse and misuse by counting, securing and disposing of medications properly.