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Blue Cross Blue Shield offers Medicare prescription drug plans that cover prescription drug costs for covered medications. The specific medications covered depend on the plan. To find out what medications are covered under your plan, you can refer to your Evidence of Coverage, Certificate of Insurance, or medication guide. These resources will outline the medications covered and any special rules or restrictions. Blue Cross Blue Shield also provides tools and resources to help you understand your prescription drug coverage and find in-network pharmacies.
| Characteristics | Values |
|---|---|
| Medication guide | Lists all the drugs covered by the plan and any rules for certain medications |
| Plan tiers | Higher tiers have higher costs, and lower tiers have lower costs |
| Non-formulary medication | Medication not on a patient's medication list |
| Specialty drugs | Only available through a Blue Shield Network Specialty Pharmacy |
| Medicare Part D | Prescription drug plans offered by Blue Cross and Blue Shield |
| Medicare Part D eligibility | Aged 65 or above, disabled, diagnosed with end-stage renal disease or amyotrophic lateral sclerosis |
| Medicare Part D low-income subsidy program | Financial assistance with medication costs based on income and assets |
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What You'll Learn
Medicare Part D prescription drug plans
Blue Shield offers standalone Medicare Prescription Drug Plans (PDP) that provide a variety of coverage options for your prescription drug costs. These plans can be added to your existing Medicare coverage. Blue Shield PDP plans cover most Part D vaccines at no cost to you, even if you haven't paid your deductible. Insulin products are also covered by Blue Shield Prescription Drug plans, with a cap of $35 for a one-month supply per product.
MedicareBlue Rx is a Prescription Drug Plan (PDP) with a Medicare contract. It covers a large list of drugs (or formulary) selected for their value and effectiveness. However, it does not cover every type of prescription drug. Enrollment in MedicareBlue Rx depends on contract renewal and is available to residents of specific service areas or members of certain employer or union groups.
Beginning in 2025, Medicare Part D enrollees will have the option to pay their out-of-pocket Part D prescription drug costs in monthly amounts over the course of the plan year. Most Part D plans have formularies, which are lists of covered prescription drugs, and they also have networks of approved pharmacies in your area. Costs for Part D plans can vary, so it's important to choose a plan that meets your budget and needs.
Blue Distinction Centers are facilities or providers that are part of your health plan network. When selecting a Blue Distinction Center, be sure to confirm that it is included in your health plan network and check your coverage manual to understand the specific requirements for certain procedures to be covered.
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Non-formulary medications
Specialty drugs are limited to a 30-day supply and must be obtained from an in-network specialty pharmacy for a patient's benefits to apply. The in-network pharmacy options depend on the patient's plan benefits. Requests for non-formulary medications can be submitted online using CoverMyMeds, MHK Provider Portal, or SureScripts.
Blue Cross NC may restrict the amount of medication covered by an insurance plan to encourage the proper use of prescription medications. This may involve reducing the number of pills taken daily without altering the medication's total strength. Patients may be covered for a restricted medication if their provider confirms in writing that the non-restricted medication was ineffective or potentially harmful.
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) offer medication plans to cover prescription medications obtained at a pharmacy. Each medication plan includes a list, or formulary, detailing the covered medications. Patients can determine if they have medication coverage by looking for the "Rx" on their member ID card. The letter following "Rx" indicates the drug list or formulary that the patient's plan uses, while the number provides information about in-network pharmacies.
To find out if a specific medication is covered, patients can visit the Find Care page and select the "Drug or pharmacy" option. After selecting the letter code that matches the medication, they will be directed to the Prime Therapeutics website. Blue Cross NC also provides assistance in finding a formulary, searching for medications, and obtaining prior approvals.
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Preventive drugs
Texas
Blue Cross and Blue Shield of Texas offers a quick view of covered items for preventive drugs. To find out if your medication is covered, log in to your member account and use the drug finder tool. You can also call Customer Service at the number listed on your member ID card to confirm your correct drug list.
Illinois
Blue Cross and Blue Shield of Illinois also offers a quick view of covered items for preventive drugs. To find out if your medication is covered, log in to your Blue Access for MembersSM account and search for your medication. You can also call Customer Service at the number listed on your member ID card to confirm your correct drug list.
California
Blue Shield of California offers preventive health drugs that require a valid prescription, including over-the-counter (OTC) products, to be covered under the pharmacy benefit. To find out if your medication is covered, refer to your Evidence of Coverage or Certificate of Insurance to determine your plan name. You can also call the phone number listed on your Blue Shield member ID card for any questions about preventive health drugs.
Florida
Florida Blue offers a medication guide that lists all the drugs covered by your plan, as well as any special rules for certain medications. To access the medication guide, log in to your member account and look under Pharmacy Resources.
Indiana
If your employer's health plan is with Blue Cross Blue Shield Indiana, you will need to choose Indiana to access the correct drug list.
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Contraceptive drugs
For FEHB members, contraceptive coverage is available at no cost. This includes at least one option in all methods of contraception, as well as screening, education, counselling, and follow-up care. If a contraceptive is not available without cost sharing, it can be accessed through the contraceptive exceptions process.
For Blue Cross and Blue Shield of North Carolina (Blue Cross NC) members, each medication plan comes with a list (or formulary) that shows what medications are covered. To encourage the proper use of prescription medications, Blue Cross NC may restrict the amount of medicine covered under an insurance plan. This may mean taking fewer pills each day without changing the total strength of the medication. Blue Cross NC requires that patients first try a medication or device that is not restricted before approving a restricted medication.
For Blue Cross and Blue Shield of California members, refer to your Evidence of Coverage or Certificate of Insurance to determine your plan name. Then, refer to your plan's drug formulary for a list of preferred generic and brand-name medications. The contraceptive drug list will show which drugs and devices are covered at $0 member share of cost.
For Blue Cross and Blue Shield of Louisiana members, most plans include contraceptive care options. Many plans cover certain contraceptive care prescribed for women with reproductive capacity for $0 out of pocket when obtained in-network. Commonly covered contraceptives include FDA-approved contraceptive care prescribed or provided by a doctor, such as barrier methods (e.g. vaginal rings, diaphragms, sponges, condoms) and implanted devices (e.g. rods, intrauterine devices or IUDs with copper or progestin).
For Florida Blue members, refer to the medication guide for your specific plan to see what drugs are covered. Each plan has its own medication guide, which can be found under Pharmacy Resources when logged into your member account.
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Restricted medications
Blue Cross Blue Shield offers a range of Medicare prescription drug plans that cover prescription drug costs for certain medications. These plans are offered by private health insurance companies like Blue Cross and Blue Shield.
Medicare Part D is a prescription drug plan that is generally included in most Medicare Advantage (Part C) plans. Part D insurance premiums may change annually, and beneficiaries are notified of these changes before the annual Open Enrollment Period.
Blue Cross NC also offers medication plans that cover the medications patients get at their pharmacy. Each medication plan has a list (or formulary) that details the medications covered.
However, Blue Cross NC may restrict the amount of medicine covered under an insurance plan. This could mean reducing the number of pills a patient takes daily without altering the total medication strength. Blue Cross NC requires patients to first try a non-restricted medication before approving a restricted one. For a restricted medication to be covered, providers must inform Blue Cross NC in writing that:
- The patient has already used the non-restricted medication, but it was ineffective or harmful.
- The non-restricted medication is likely to be ineffective or harmful to the patient's health.
Additionally, Blue Shield of CA provides drug formularies that list preferred generic and brand-name medications. They also offer a specialty drug list for specialty drugs only available through their network specialty pharmacy.
To find out which medications are covered under your specific Blue Cross Blue Shield plan, refer to your Evidence of Coverage, Certificate of Insurance, or medication guide. These resources will outline the medications included in your plan's formulary or drug list.
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Frequently asked questions
You can log in to your Blue Access for Members account and search for covered medications. You can also call the Pharmacy Member Services number printed on your ID card.
If the medication you need is not on your drug list, you may be able to apply for coverage using a Non-Formulary Exception Process (NFE) form. You can also ask for an expedited review process, and Blue Cross will let you know the coverage decision within 24 hours.
Blue Cross offers prescription drug cost tools and discount programs to help make your medications more affordable. You can also switch to a generic medication to save on costs.
Yes, there are some medications that are not covered by Blue Cross insurance plans. These may include medications that are not on your specific drug list or formulary.
If you have a medication plan with Blue Cross, you will see an Rx on your member ID card. This indicates that you have medication coverage.
