Frequently Asked Questions

Your prescription drug plan uses a drug list. It is a list of drugs based on the recommendations of a group of experts with a medical or pharmacy degree. They base their decisions on safety, cost and how well the drugs work. They review and update each list regularly. Each drug on the list is approved by the U.S. Food and Drug Administration.

If you’ve been told a prescription medicine isn’t covered, the first step is to find out more. Learn why the medicine is not covered. Ask the pharmacist. Check to see that it’s not a paperwork issue, like not getting pre-approval, also called prior authorization. Here's an article that may help or visit our Transparency in Coverage page.

Most drug lists have levels of coverage, called tiers. Each tier has its own cost. Your drug list may have up to 6 tiers. Often, your copayment or coinsurance amount is less for covered drugs in a lower tier. For example, brand drugs may be in a higher tier and their generic equivalent may be in a lower tier and cost you less.

There are a few ways to check if your medication is included in your drug list.

• The best way to check is through the member portal, Blue Access for Members^SM. After you log in to your member account,  click on the Pharmacy tab and search for a medication. You'll get information about that drug, including coverage and cost details.
• If you know the name of your plan or your drug list, you can find your drug list without logging in to your account.
• You can talk to your doctor or pharmacist.

There are two types of generic drugs.

1. A generic equivalent has the same active ingredient(s) at the same dose as the brand drug. A doctor can switch a brand drug for a generic equivalent. Often, a pharmacist can help you make the switch too.
2. A generic alternative can treat the same condition. But the active ingredient(s) are not the same as the brand drug. Only you and your doctor can decide if a generic alternative to a brand drug is right for you. If it is, your doctor must write a new prescription. 

Generics often cost less than a brand drug. The FDA reviews and approves generic drugs for use just like they approve brand drugs. Talk to your doctor or pharmacist to find out if a generic drug is right for you. Get more information about generic drugs from our member flier .

A generic equivalent has the same active ingredient(s) as the brand drug at the same dose. Not all prescription drugs have a generic equivalent.

Most of the time, your pharmacist can switch a brand drug with a generic equivalent.

According to the FDA, an approved generic equivalent drug:

• Is chemically the same.
• Works just as well in the body.
• Works safely.
• Meets the same standards set by the FDA.

A generic alternative can treat the same condition as a brand drug. The active ingredients are different. Only you and your doctor can decide if a generic alternative is right for you. In that case, your doctor must write a new prescription.

Here are some tips if you would like to switch your brand drug prescription with a generic.

Talk to your doctor about using generic drugs. Ask your doctor to check your prescription drug list. Drugs on the list are chosen based on their safety, cost and how well they work. The drug list includes brand drugs, generic alternatives and generic equivalents.

Your pharmacist can help too. Sometimes a pharmacist can communicate with your doctor on your behalf. Depending on your plan, your pharmacist may be able to replace the brand drug with a generic equivalent.

Finally, log into your member account  for help and click on the Pharmacy tab. You can get an estimate of your out-of-pocket cost for a prescription by using the drug search  tool.

No. Not all brand drugs have a generic available.

There are two types of generic drugs. A generic equivalent has the same active ingredient(s) at the same dose as the brand drug. A generic alternative can treat the same condition, but the active ingredient(s) are not the same.

For most brand drugs, there is a generic option. The newest drugs on the market may not have generic equivalents available.

For questions about your treatment, talk to your doctor or pharmacist. Treatment decisions are always between you and your doctor.

For help with benefits and costs, log in to your member account  and click on the Pharmacy tab. Here, you can:

• Search for pharmacies .
• Look up medications .
• Open your Medicine Cabinet . 
• Review your prescription coverage .

If you need more help, you can call Customer Service at the number on your ID card.

Some prescriptions need approval before your benefit plan covers them. Prior authorization helps make sure the drug is prescribed, managed, and taken safely.

If your drug is part of this program, your doctor will need to submit information first. If it’s approved, you will pay for your share of the drug based on your benefit plan. If it’s not approved, the drug will not be covered under your benefit plan. You can still get your prescription. But you may have to pay the full amount.

Treatment decisions are always between you and your doctor. Get our member flier for more details.

There are a few different ways.

1. The best way is to log in to your member account , click on the Pharmacy tab and search for a medication. In the search results, information about that drug will appear, including if the drug needs prior authorization.
2. Most of the time, your pharmacist will notify you if a prescription needs prior authorization. 
3. If you know the name of the drug list associated with your health plan, you can get the list of medications requiring prior authorization without logging in to your account.

A team of experts reviews drugs that need prior authorization. The team is made up of doctors and pharmacists. They review the drug labels approved by the FDA. They also review scientific studies and national guidelines. They use this information to make informed decisions.

Mostly, your doctor must act. Your doctor can find prior authorization information and forms on our website. 

If it’s approved, you will pay your cost share for the drug based on your benefits. If it’s not approved, the drug will not be covered. You can still fill the prescription, but you will have to pay the full amount.

Cost is only one factor in choosing medication. As always, treatment decisions are between you and your doctor.

Step therapy is a prescription program to encourage the use of preferred drugs before trying a non-preferred drug. Preferred drugs are safe and work well in treating a specific medical condition. They are also a cost-effective choice. Often, a non-preferred drug costs more.

It’s like climbing stairs. You start with step one before moving up to step two.

Step 1
If possible, your doctor should prescribe a preferred medication right for your condition.

Step 2
You and your doctor might decide the first-line drug is not right for you or isn’t as good at treating your condition. If so, then your doctor should request an exception.

Get our step therapy member flier for more information.

Treatment decisions are between you and your doctor. You and your doctor might decide the first-line drug is not right for you or isn’t as good at treating your condition. Your doctor can submit an exception request through our provider site. 

There are a few different ways.

1. The best way is to log in to your member account , click on the Pharmacy tab and search for a medication. In the search results, information about that drug will appear, including if the drug needs step therapy.
2. Most of the time, your pharmacist will notify you if a prescription requires step therapy. 
3. If you know the name of the drug list associated with your health plan, you can get the list of drugs requiring step therapy without logging in to your account.

Dispensing limits are rules around the amount of a prescription drug you can fill at a pharmacy at one time. Limits are often based on the drug maker's research. You and your doctor may decide you need more of a drug than what the dispensing limit allows. In that case, you can still get the drug. But you may be responsible for the full cost of the drug based on your benefit plan.

There are a few different ways.

1. The best way is to log in to your member account , click on the Pharmacy tab and search for a medication. In the search results, information about that drug will appear, including if the drug has dispensing limits.
2. Most of the time, your pharmacist will notify you if a prescription has dispensing limits. 
3. If you know the name of the drug list associated with your health plan, you can get the list of medications with dispensing limits without logging in to your account.

There are a few different types of pharmacies.

• Retail Pharmacies: Retail pharmacies are independent from the healthcare provider, a hospital or a doctor's office. Generally, they offer prescription and over-the-counter drugs and healthcare products and devices. National chain drugstores and grocery stores are retail pharmacies. Regional, local and independent pharmacies may also be retail pharmacies. Walgreens is an example of a retail pharmacy.
• Specialty Pharmacies: Drugs that treat some conditions may have special handling or storage needs. Because of those needs, retail pharmacies may not stock specialty drugs. That’s why members may need to use a specialty pharmacy to fill specialty prescriptions.
• Home Delivery Pharmacies: Home delivery or mail order pharmacies can ship some types of medications to your home. These include maintenance drugs that treat longer-term conditions.
• Vaccine Pharmacies: You can get some vaccines at a nearby pharmacy. They may be covered by your plan. More information is available in our member flier .

Get details about the different types of pharmacy networks available to members with our prescription and pharmacy coverage.

Retail pharmacies are independent from the healthcare provider, a hospital or a doctor's office. Generally, they offer prescription and over-the-counter drugs and healthcare products and devices. National chain drugstores and grocery stores are retail pharmacies. Regional, local and independent pharmacies may also be retail pharmacies. Walgreens is an example of a retail pharmacy.

Drugs that treat some conditions may have special handling or storage needs. Because of those needs, retail pharmacies may not stock specialty drugs. Some do, others don't. That’s why members may need to use a specialty pharmacy to fill specialty prescriptions.

Home delivery or mail order pharmacies can ship some types of medications to your home. These include maintenance drugs that treat longer-term conditions.

You can get some vaccines at a nearby pharmacy. They may be covered by your plan. More information is available in our member flier .

To find out if a prescription is covered and what you will pay for it, log in to your member account  for help. Here, you can:

• Look up medications . 
• Review coverage . 

For questions about your treatment, talk to your doctor or pharmacist. Treatment decisions are always between you and your doctor.

For help with benefits and costs, log in to your member account . Here, you can do the following. Note: these links are for those members with our prescription and pharmacy benefits.

• Search for pharmacies .
• Look up medications .
• Open your Medicine Cabinet . 
• Review coverage .

If you need more help, you can call Customer Service at the number on your ID card.

Make sure you fill your prescriptions at an in-network pharmacy. In some cases, you can have prescriptions delivered to your home. To find a pharmacy, log in to your member account  . 

Specialty drugs are used to treat conditions that are any of the following:

• Rare or less common conditions like multiple sclerosis
• Serious conditions like cancer or hemophilia
• Long-term conditions like rheumatoid arthritis

Drugs that treat these conditions often have special handling or storage needs. Chain or independent pharmacies (also called retail pharmacies) may not stock these types of drugs. That’s why members may need to use a specialty pharmacy to fill specialty prescriptions. Your prescription and pharmacy benefits include a specialty pharmacy network. See our member flier for more on specialty drugs and the specialty pharmacies that carry them. 

When you fill a prescription from an in-network pharmacy for a brand drug where a generic equivalent is available, you may pay more. You may pay the copay or coinsurance amount plus the difference in cost between the brand drug and its generic equivalent. This may apply even if your doctor writes “do not substitute” on your prescription. Not all members have the Member Pay the Difference Program. 

Get our Member Pay the Difference Program member flier for more information.

We look at your prescription fills over the past six months. If your prescription has refills and has not expired, you can get a refill when you have used about 75% of that medication. If it’s too soon for a refill, the pharmacist can tell you the date when you can get more medication.

Here’s an example: You have a prescription for 30 pills per fill with more than one refill allowed. You can refill the prescription when you’ve used about 75%, or 22 pills in this example. You also cannot have more than seven extra pills on hand over six months.

Some medications have exceptions based on state laws. We also keep in mind special situations like vacations, or if your medication is lost or stolen.

MedsYourWay is a prescription and pharmacy benefit. It automatically applies drug discount card prices on eligible prescriptions. Just show your member ID card at an in-network pharmacy to see if you could save. Learn more .

Synagis helps protect high-risk babies from severe respiratory syncytial virus, also known as RSV. Synagis is not a vaccine. It’s an injection given once a month usually during the colder months when RSV is more common. If Synergis is medically necessary, the Synagis Prior Authorization/Statement of Medical Necessity/Order Form can be submitted.

Complete and maintain a patient medication list form . It's also available in Spanish.