Pharmacy Programs

These pharmacy programs are available for members.

Prior Authorization/Step Therapy Program

The prior authorization/step therapy program is designed to encourage safe, cost-effective medication use.

This program may be part of your prescription drug benefit plan. To find out if your specific benefit plan includes the prior authorization/step therapy program, and which drugs are part of your plan, refer to your benefit materials, or call the number on the back of your ID card.

Prior Authorization

Under this program, your doctor will be required to request pre-approval, or prior authorization, through Blue Cross and Blue Shield of Texas in order for you to get benefits for the select drugs.

  • Examples of drug categories and specific medications for which a prior authorization program may be included as part of your prescription drug benefit plan are listed below.
  • Please note that not all drug categories are included in all benefit plans. Additional drug categories may be added and the medications listed are only examples. Call the number on the back of your ID card with questions about a specific medication.
  • If you are taking, or prescribed, a drug that is newly introduced to the market, you may need to have your doctor submit a prior authorization request in order to get benefits for such drugs. If you have questions about your medicine, call the number on the back of your ID card.
  • As always, cost is only one factor in choosing medication and treatment decisions are between you and your doctor.
Prior Authorization Category Prescription drugs within category 1
Addyi Addyi
Afrezza Afrezza
Androgens/Anabolic Steroids Anadrol-50, Androderm, Androgel, Android, Androxy, Aveed, Axiron, danazol, Delatestryl, Depo-Testosterone, First-Testosterone, Fortesta, Methitest, Natesto, Oxandrin, Striant, Testim, Testone CIK, Testopel, Testred, Vogelxo
Antifungal Agents Cresemba, Noxafil, Vfend
Cerdelga Cerdelga
Circadian Rhythm Disorders Hetlioz
Cystic Fibrosis Kalydeco, Orkambi
Doxycycline/Minocycline Doxycycline products: Acticlate, Adoxa, Alodox, Avidoxy DK, Doryx (and generic equivalents), Doryx MPC (and generic equivalents), doxycycline, Monodox, Morgidox Kit, Nicazeldoxy, Nutridox Kit, Ocudox Kit, Oracea, Oraxyl, Targadox, Vibramycin
Minocycline products: Dynacin, Minocin, Minocin Kit, Solodyn (and generic equivalents)
Enzyme Deficiencies Kuvan
Erectile Dysfunction2 Caverject, Cialis, Edex, Levitra, Muse, Staxyn, Stendra, Viagra
Erythropoiesis Stimulating Agents (ESAs) Aranesp, Epogen, Mircera, Procrit
Growth Hormones Egrifta, Genotropin, Humatrope, Norditropin, Nutropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Tev-Tropin, Zomactin, Zorbtive
Hepatitis B & C Daklinza, Epclusa, Harvoni, Olysio, Pegasys, PegIntron, Sovaldi, Technivie, Viekira PAK, Viekira XR, Zepatier
Huntington's Chorea Xenazine
Hypercholesterolemia Juxtapid, Kynamro, Praluent, Repatha
Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker Corlanor
Idiopathic Pulmonary Fibrosis (IPF) Esbriet, Ofev
Inherited Autoinflammatory Disorders Arcalyst, Ilaris
Insulin Agents Apidra, Humalog, Humalog KwikPen U200, Humalog Mix 75/25, Humalog Mix 50/50, Humulin R U-100, Humulin N, Humulin 70/30
Korylm Korlym
Multiple Sclerosis Amprya
Myalept Myalept
Narcolepsy Nuvigil, Provigil
Natpara Natpara
Neprilysin Inhibitor Entresto
Ocaliva Ocaliva
Ophthalmic Immunomodulators Restasis, Xiidra
Opioid Dependence Bunavail, Suboxone, Subutex, Zubsolv
Oral Immunotherapy Grastek, Oralair, Ragwitek
Opioid Induced Constipation Movantik, Relistor
Osteoporosis (Bone loss) Forteo
Pituitary Hormone H.P. Acthar Gel
Pulmonary Arterial Hypertension (PAH) Adcirca, Adempas, Letairis, Opsumit, Orsenitram, Revatio, Tracleer, Tyvaso, Uptravi, Ventavis
Self-Administered Oncology Afinitor, Afinitor Disperz, Alecensa, Bosulif, Cabometyx, Caprelsa, Cometriq, Cotellic, Erivedge, Farydak, Gilotrif, Gleevec, Hexalen, Hycamtin, Ibrance, Iclusig, Imbruvica, Inlyta, Iressa, Jakafi, Lenvima, Lonsurf, Lynparza, Lysodren, Matulane, Mekinist, Nexavar, Ninlaro, Odomzo, Pomalyst, Revlimid, Sprycel, Stivarga, Sutent, Sylatron, Tafinlar, Tagrisso, Tarceva, Targretin, Tasigna, Temodar, Thalomid, Tretinoin, Tykerb, Venclexta, Votrient, Xalkori, Xeloda, Xtandi, Zelboraf, Zolinza, Zykadia, Zydelig, Zytiga
Short Bowel Syndrome Gattex
Therapeutic Alternatives Absorica, Amrix, Ativan, Bupap, Cambia, Carac/Fluorouracil, Cardizem CD, Cuprimine, Daraprim, Dexpak, Durlaza, Evzio*, Fortamet, Glumetza/metformin extended-release, Kadian, Kazano, lidocaine ointment, Lidoderm, Nesina, Northera, Onmel, Oseni, Pandel, Primlev, Rayos, Sitavig, Solaraze/generic diclofenac gel, Sporanox, Spritam, Vivlodex, Zegerid, Zyflo/Zyflo CR
Thrombopoietin Receptor Agonists Nplate, Promacta
Topical Antifungal Agents CNL8, Cicloden, Jublia, Kerydin, Pedipak, Pedipirox-4 Nail, Penlac
Transmucosal Immediate Release Fentanyl Abstral, Actiq, Fentora, Lazanda, Subsys
Urea Cycle Disorders Buphenyl, Ravicti
Xyrem Xyrem

1 Third-party brand names are the property of their respective owners.

2 Program does not apply to all pharmacy benefit plans.

*Due to Substance Abuse Parity, some members may not need to submit a PA request for Evzio to be considered for coverage.

More information is available in the prior authorization member flier PDF Document.

Step Therapy

The step therapy program requires that you have prescription history for a "first-line" medication before your benefit plan will cover a "second-line" drug.

  • A first-line drug is recognized as safe and works well in treating a specific medical condition, as well as being a cost-effective treatment option.
  • A second-line drug is a less-preferred or likely a more costly treatment option.

Step 1: If possible, your doctor should prescribe a first-line medication right for your condition.

Step 2: If you and your doctor decide that a first-line drug is not right for you or is not as good in treating your condition, your doctor should submit a prior authorization request for coverage of the other drug.

  • Below are examples of drug categories and specific medications for which a step therapy program may be included as part of your prescription drug benefit plan.
  • Step therapy does not apply to the generic equivalents for these medications (if available), so if you and your doctor decide the generic equivalent is best for you, prior authorization is not required.
  • These medications are listed along with the first use approved by the U.S. Food and Drug Administration, but may be prescribed for conditions other than those noted and would still be part of the step therapy program.
  • Please note that not all drug categories are included in all benefit plans. Additional categories may be added and the medications listed are only examples. Call the number on the back of your ID card with questions about a specific medication.
  • As always, cost is only one factor in choosing medication and treatment decisions are between you and your doctor.
Step Therapy Category Prescription Drugs within the Category1
Antidepressants(depression) Aplenzin, Celexa, Cymbalta, desvenlafaxine ER tabs, Desvenlafaxine fumarate, Duloxetine, Effexor, Effexor XR, Fetzima, fluoxetine 60 mg tabs, Forfivo XL, Irenka, Khedezla, Lexapro, Luvox CR, maprotiline, Oleptro, Paxil, Paxil CR, Pexeva, Pristiq, Prozac, Prozac Weekly, Remeron, Remeron SolTab, Trintellix, venlafaxine ER tabs, Viibryd, Viibryd Starter Kit, Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zoloft
Atopic Dermatitis (eczema) Elidel, Protopic/tacrolimus
Atypical Antipsychotics Abilify, Abilify Discmelt, Abilify Maintena, Aristada, clozapine ODT, Clozaril, Fanapt, FazaClo, Geodon, Invega, Invega Sustenna, Invega Trinza, Latuda, Rexulti, Risperdal, Risperdal M-Tab, Risperdal Consta, Saphris, Seroquel, Seroquel XR, Versacloz, Vraylar, Zyprexa, Zyprexa Zydis, Zyprexa Relprevv
Biologic Immunodulators (rheumatoid arthritis/psoriasis) Actemra subcutaneous, Cimzia, Cosentyx, Enbrel, Entyvio, Humira, Humira starter kit, Kineret, Orencia subcutaneous, Otezla, Simponi, Stelara, Taltz, Xeljanz, Xeljanz XR
Cholesterol (lipid management) Advicor, Altoprev, Lescol, Lescol XL, Lipitor, Liptruzet, Livalo, Mevacor, Pravachol, Simcor, Vytorin, Zocor
COX-2 /NSAID GI Protectant (pain management) Celebrex, Duexis, Vimovo
Diabetes (GLP-1 Receptor Agonists) Bydureon, Byetta, Tanzeum, Trulicity, Victoza
Fibrates Antara, Fenoglide, Fibricor, Lipofen, Lofibra, Tricor, Triglide, Trilipix
Glucose Test Strips All non-preferred brand test strips and disks
Infertility2 Bravelle, Gonal F, Gonal F RFF
Iron Chelator Ferriprox
Multiple Sclerosis Aubagio, Avonex, Extavia, Gilenya, Zinbryta
Ophthalmic Prostaglandins
(glaucoma)
Lumigan, Rescula, Travatan Z, Travoprost, Xalatan, Zioptan
Topical Non-Steroidal Anti-Inflammatory Drug Flector, Pennsaid, Voltaren

1 Third-party brand names are the property of their respective owners.

2 Program does not apply to all pharmacy benefit plans.

More information is available in the step therapy member flier PDF Document.

If you have questions about the prior authorization/step therapy program, call the number on the back of your BCBSTX ID card.

Specialty Pharmacy Program

Your prescription drug benefit may include a specialty pharmacy program through Prime Therapeutics Specialty Pharmacy (Prime Specialty Pharmacy).

Specialty medications are those used to treat serious or chronic conditions. Examples include hepatitis C, hemophilia, multiple sclerosis and rheumatoid arthritis. These drugs are typically given by injection, but may be topical or taken by mouth. They often require careful adherence to treatment plans, have special handling or storage requirements, and may not be stocked by retail pharmacies.

When you purchase specialty medications through Prime Specialty Pharmacy, you can have your self-administered specialty medications delivered directly to you, or to your doctor's office. You also receive at no additional charge:

  • Support services for managing your drug therapy
  • Educational materials about your particular condition
  • Help with managing potential medication side effects
  • 24/7/365 customer service phone access

BCBSTX members who use oral oncology or hemophilia specialty drugs may have other in-network specialty pharmacy options. Log in to your Blue Access for MembersSM account to find a preferred specialty pharmacy near you.

Note: Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC, a pharmacy benefit management company. BCBSTX contracts with Prime Therapeutics to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSTX, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

Mail Service Program

PrimeMail®, the mail service pharmacy for members with BCBSTX prescription drug coverage, provides safe, fast and cost-effective pharmacy services that can save you time and money. With this program, you can obtain up to a 90-day supply of long-term (or maintenance) medications through PrimeMail. Maintenance medications are those drugs you may take on an ongoing basis to treat conditions such as high cholesterol, high blood pressure or diabetes. View the maintenance drug list PDF Document to see if your medication is included.

Ordering Through PrimeMail

  • When you log in to Blue Access for Members and visit your Rx Drugs page, you can use the online order form, print an order form to mail or ask that PrimeMail get in touch with your doctor to request a new prescription.

For more information about using mail service:

Vaccine Program

If you have coverage through Blue Cross and Blue Shield of Texas, vaccinations may be covered under the medical benefit or the prescription drug benefit, based on your plan. These vaccines can help protect you from illnesses such as the flu, pneumonia, shingles, rabies, hepatitis B, meningitis, HPV, tetanus, diphtheria and pertussis.

To learn more about which vaccines are available under your plan for you and your covered family members, check your benefit materials for details and any necessary copays. Or, you can call the Pharmacy Program number on the back of your ID card.

  • For vaccinations covered under the prescription drug benefit, select vaccines can be conveniently administered at a participating vaccine network pharmacy near you. Just hand your ID card to the pharmacist.
  • To see a complete list of all participating pharmacies, search the pharmacy network on myprime.com and filter for vaccine pharmacies. Or, you can call the number on the back of your ID card.
  • Before you go, be sure to confirm the location's participation and hours, vaccine availability and ask about any other age limits, restrictions or requirements that may apply.