• What is a prescription drug list?
• Can I use a medication my doctor prescribes if it is not on the Drug List?
• What is a 3-Tier or 4-Tier prescription drug plan?
• What is a specialty pharmacy drug?
• What are generic drugs?
• What is prior approval/authorization?
• What is a dispensing limit (DL)?
• What is Step Therapy?
• What is a 25/50 percent prescription drug plan?
• Who do I contact if I have questions?
What is a prescription drug list?
The Blue Cross and Blue Shield of New Mexico (BCBSNM) Drug List is a list of prescription drugs that are available to members at lower copayment levels. Drugs not on the list are still covered but require a higher copayment. BCBSNM and the Prime Therapeutics National Pharmacy and Therapeutics (P&T) Committee meet to make formulary recommendations and evaluate drugs for therapeutic uniqueness, safety, and cost before including them on the Drug List. Your physician should consult our Drug List when making prescription drug decisions for you.
Can I use a medication that my doctor prescribes if it is not on the Drug List?
Yes, drugs not listed are covered with BCBSNM's 3-Tier and 4-Tier prescription drug plans. You have benefit coverage for most drugs, even if they are not on the Drug List. You will pay the higher 3-Tier or 4-Tier copayment.
What is a 3-Tier or 4-Tier prescription drug plan?
Our 3-Tier and 4-Tier prescription drug plans allow you to get a prescription drug even if it's not on the BCBSNM Drug List and to get a brand-name drug even when a generic-equivalent is available. Make sure to have your prescriptions filled at either a participating pharmacy (search the Provider Finder® to locate a pharmacy in New Mexico) or through the PrimeMail Pharmacy Program, our managed prescription mail-order service.
Your copayment is based on whether you are receiving a generic drug or a brand-name drug AND whether the drug is on our Drug List.
| Tier 1=lowest copayment | You pay this amount when you receive a generic drug. |
| Tier 2=middle copayment* | You pay this amount when you receive a brand-name drug that is on our drug list and no generic is available. |
| Tier 3=highest copayment* | You pay this amount when you receive a brand-name drug that is not on our drug list. |
| Tier 4=specialty drug** | You pay a copay or percentage based on your plan benefits. |
*If you or your doctor prefer that you receive a brand-name drug when a generic equivalent is available, you'll pay the Tier 1 copayment PLUS the difference in cost between the generic and brand-name drug.
For commercially packaged items (such as inhalers, tubes of ointment, drug blister packs, insulin or boxes of test strips), you will pay the applicable copayment for each package, regardless of the days' supply the package represents. For example, if two inhalers are purchased under the Retail Pharmacy Program, two copayments will apply. Under the PrimeMail Pharmacy Program, you may receive up to three packages (a 90-day supply) via mail order for only 2 or 2-1/2 times the retail copayment depending on your plan.
**Specialty pharmacy drugs are used to treat serious and/or chronic conditions such as multiple sclerosis, pulmonary hypertension, hepatitis, and rheumatoid arthritis. These medications are typically injectable and can be administered by a patient or family member. Members must use a contracting specialty network pharmacy to fill these specific prescriptions.
See your Benefit Booklet, Benefit Summary, or Prescription Drug Plan Rider for details, limitations, and exclusions.
What is a specialty pharmacy drug?
Specialty pharmacy drugs are used to treat serious and/or chronic conditions such as multiple sclerosis, pulmonary hypertension, hepatitis, and rheumatoid arthritis. These medications are typically injectable and can be administered by a patient or family member. Members with health coverage that includes specialty pharmacy benefits must use a contracting specialty network pharmacy to fill these specific prescriptions.
What are generic drugs?
A generic drug is a version of a brand drug. According to the U.S. Food and Drug Administration (FDA), compared to the brand drug, a generic:
- is chemically the same
- works the same in the body
- is just as safe and effective
- meets the same standards set by the FDA
- often costs much less
What is prior approval/authorization?
Certain drugs require approval from BCBSNM. If approval is not obtained, BCBSNM will not pay for them. The list of drugs that require prior approval (PA) is in the Drug List. To request prior approval, your doctor must call BCBSNM Health Services Pharmacy Department.
What is a dispensing limit (DL)?
Some drugs have limits to how many tablets or how much liquid can be filled in a month. This is based on the drug maker's research and FDA approval. If your doctor thinks you need more of a drug, he/she can call the BCBSNM Health Services Pharmacy Department.
BCBSNM asks members to use approved generic drugs to treat medical conditions before we cover a brand drug for the same treatment. Some brand drugs require prior approval if a generic is not used first. Ask your doctor if a generic can be used before he or she prescribes a brand drug that requires step therapy.
What is a 25/50 percent prescription drug plan?
The 25/50 Percent Prescription Drug Plan is a plan where:
You pay 25 percent of the retail cost for generic drugs and 50 percent of the retail cost for brand-name drugs, unless the retail drug cost is high enough or low enough that a maximum or minimum copayment applies (see table below). If the cost of a drug or other covered item is less than the minimum copayment, you pay only the retail cost.
Generic Drugs |
Brand-Name Drugs |
||
| Retail Cost | Your Cost |
Retail Cost | Your Cost |
| $0 - $20 | You pay retail cost | $0 - $40 | You pay retail cost |
| $20 - $80 | $20 copayment (minimum copayment) | $40 - $80 | $40 copayment (minimum copayment) |
| $80 - $300 | 25% of retail cost (calculates to between $20 - $75) | $80 - $250 | 50% of retail cost (calculates to between $40 - $125) |
| $300 + | $75 copayment (maximum copayment) | $250 + | $125 copayment (maximum copayment) |
Your annual cost for prescription drugs and other covered items never exceeds the $2500 prescription drug out-of-pocket limit; when this limit is reached, the drug plan pays 100% of covered charges for the remainder of the calendar year. This limit, which includes coinsurance and copayments, is separate from the medical plan's out-of-pocket limit.
The BCBSNM Drug List does not apply with the 25/50 Percent Prescription Drug Plan.
See your plan Benefit Booklet, Benefit Summary, or Prescription Drug Plan Rider for more details about prescription drug benefits.
Who do I contact if I have questions?
You should discuss questions and concerns about drugs that you are taking with your physician. He or she can discuss whether a BCBSNM listed medication is appropriate for you. If you have any questions about your prescription drug benefits, call Customer Service at 1-877-357-7463.
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