CHIP Prescription Drug Frequently Asked Questions
BCBSTX covers most of the prescription drugs that your Primary Care Provider (PCP) thinks you need. BCBSTX uses a chosen list of drugs called a preferred drug list to help your doctor choose which drugs to give you. Certain drugs on this list need an OK ahead of time or have limits based on medical necessity. In these cases, your doctor must ask for an OK before you get the drug.
You must get our OK before we pay for drugs that are not on the list. If your doctor thinks you need to take a drug that is not on the list, your doctor will send us a request that tells us why you need the drug. We will let your doctor know if we say “yes” to your request within 24 hours. If we get the request after hours, we will let your doctor know on the next business day. Your pharmacist can ask for a 72-hour supply of the drug if we get the request after hours. If we say “no” to your request, you will get a letter that tells you the medical reasons why.
There are two kinds of drugs on the preferred drug list: brand-name and generic. A brand-name drug is a drug that is made by one company. A generic drug is the same drug without a brand. Generic drugs are approved by the Food and Drug Administration (FDA) and they are a safe, equally effective option to brand-name drugs. Generic drugs require the same testing as brand-name drugs, and are no different when it comes to strength, dosage, form, route of administration or intended usage. You can often buy brand-name and generic drugs at the same pharmacy.
Most of the time, brand-name drugs are covered only if there is no generic drug available. We may pay for brand-name drugs in cases where your doctor writes on the prescription that you need the brand-name drug.
Your doctor may suggest you get an over-the-counter (OTC) drug. OTC drugs are not included in your benefit.
To find out if a drug is on our list, please call our Customer Care Center at 1-888-292-4480 or the TTY number at 1-888-292-4485 or visit the formulary drug search.
Your doctor will write a prescription so you can take it to the drug store, or your doctor may be able to send the prescription for you. Make sure to take your BCBSTX ID card and Your Texas Benefits Medicaid Card to the drug store with you.
You can get your prescriptions at one of our many network drug stores. You can find a list of these pharmacies in our Pharmacy Directory or you may call our Customer Care Center at 1-888-292-4480. Members with hearing or speech loss may call the TTY line at 1-888-292-4485. Try to use the same pharmacy to get more personal service.
If you go to a drug store that is not in the network, ask the drug store staff to call our Customer Care Center at 1-888-292-4480.
If you need to fill a prescription while you are traveling or out of the service area, call our Customer Care Center at 1-888-292-4480 or the TTY number at 1-888-292-4485.
If your doctor cannot be reached to approve a prescription, you may be able to get a three-day emergency supply of your medication. Call our Customer Care Center toll-free at 1-888-292-4480 for help with your medications and refills. Members with hearing or speech loss may call the TTY line at 1-888-292-4485.
Call our Customer Care Center toll-free at 1-888-292-4480 if you have problems getting your prescriptions or if you lose your medications. Members with hearing or speech loss may call the TTY line at 1-888-292-4485.
These are some of the limits that apply to your Prescription Drug Benefit:
- Substances that are not controlled are limited to a 34-day supply.
- Some supplies are covered by your medical benefits, not your pharmacy benefits. This includes:
- Blood sugar monitors
- Nutritional products
- Injections that must be given by your PCP (office-based injections) are covered by your medical benefits, not your pharmacy benefits.
- We do not cover:
- Drugs used to treat erectile dysfunction
- Drugs ordered mostly for cosmetic reasons
- Drugs used to help hair grow
- Drugs not approved by the FDA
|Member Type||Copay for up to 34 day supply|
|CHIP < 100% FPL||$0 for generic; $3 for brand name|
|CHIP 101-150% FPL||$0 for generic; $5 for brand name|
|CHIP 151-185% FPL||$10 for generic; $35 for brand name|
|CHIP 186-200% FPL||$10 for generic; $35 for brand name|
|CHIP Perinate||No copay|
|CHIP AIAN||No copay|
|CHIP No Cost Share||No copay|
If you have any problems finding a pharmacy or getting your prescriptions, call our CustomerCare Center at 888-292-4480. Members with hearing or speech loss may call the TTY line at 1-888-292-4485.