What is a drug list?
The BCBSTX drug list, also known as a formulary, is a continually updated list of covered drugs. U.S. Food and Drug Administration (FDA)-approved drugs are chosen based on their safety, cost and how well they work. The drug list is reviewed by a group of doctors and pharmacists. This group makes routine updates based on new prescription drugs and other changes in the market. Members should show this list to their doctor and/or pharmacist. Health care providers should check the drug list when making prescription drug choices for you.
What if my doctor prescribes a drug that is not on the drug list (also known as a formulary)?
If a drug is not on the drug list, call the number on the back of your ID card to see if the drug may be covered. Based on your benefit plan, you may have to pay more for a drug that is not on the drug list.
What is a generic drug?
A generic drug is the same as a brand name drug in dose, strength, performance and use. Generics are also approved by the FDA. But generic drugs often cost less. Talk to your doctor or pharmacist about the choices you have and which drug may be right for you.
There are two types of generic drugs:
- A generic equivalent is made with the same active ingredient(s) at the same dosage as the brand drug.
Examples of a brand drug and its generic equivalent:
|Brand Drug||Generic Equivalent|
Your pharmacist can often substitute a generic equivalent for its brand counterpart without a new prescription from your doctor.
- A generic alternative is often used to treat the same condition, but the active ingredient(s) differs from the brand drug.
Your doctor can decide if a generic alternative is right for you.
Can I get a brand drug when a generic equivalent is available?
Some plans may require you to pay more if your doctor prescribes a brand drug when a generic equivalent is available. A generic equivalent is made with the same active ingredient(s) at the same dosage as the brand drug. To learn more about what you may pay, call the number on the back of your ID card.
How much will I pay for my medication?
The prescription drug list has different levels of coverage, which are called "tiers." How much you pay out of pocket for a prescription drug is often less if you choose a drug that is a lower tier.
Your prescription drug benefit plan and whether the drug is on the drug list can determine the amount you may pay out of pocket.
To find out what you may pay, log in to Blue Access for Members or call the number on the back of your ID card.
What are dispensing limits?
Some drugs may have limits on how much medicine can be filled per prescription or in a given time span. This is often based on the drug maker's research and FDA approval. If your doctor thinks you need more of a drug than what the dispensing limit allows, you can still get the drug. But you may be responsible for the full cost of the prescription, based on your benefit plan.
What is a specialty drug?
Specialty drugs are those used to treat rare or less common serious or chronic conditions. Examples are hepatitis C, hemophilia, multiple sclerosis and rheumatoid arthritis. These drugs often call for careful adherence to treatment plans, have special handling or storage needs and may not be stocked by retail pharmacies.
Some members may be required to use a select specialty pharmacy to fill these prescriptions to get the highest level of benefits.
View the Specialty Pharmacy Program Drug List which has a reminder about coverage for self-administered specialty drugs.
What is prior authorization?
The prior authorization program is designed to promote safe, cost-effective medication use.
Certain drugs may require pre-approval, called prior authorization. Your doctor will need to request prior authorization through BCBSTX in order for you to get benefits for these drugs.
- If the request is approved: You will pay for your share of the drug based on your benefit plan.
- If the request is not approved: The drug will not be covered under your benefit plan. You can still fill your prescription, but you may have to pay the full amount charged, based on your benefit plan.
Some benefit plans may also require members to try a preferred drug before coverage for a non-preferred drug is approved.
Check your benefit materials to see if your benefit plan includes the prior authorization program. To see which drugs are included, call the number on the back of your ID card.
What is step therapy?
The step therapy program requires that you have a prescription history for a "first-line" drug 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 drug 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.
Check your benefit materials to see if your benefit plan includes the step therapy program. To see which drugs are included, call the number on the back of your ID card.
What is the Member Pay the Difference Program?
Some BCBSTX prescription drug benefit plans have a Member Pay the Difference Program. The program makes sure members use medicines that are safe, work well and are cost-effective. When you fill a prescription for a covered brand name drug when a generic equivalent is available, you may pay more.
Check your benefit materials to see if your benefit plan includes the Member Pay the Difference Program. For more information about the program, call the number on the back of your ID card.
Who can I contact for questions?
You should talk to your doctor or pharmacist about any questions or concerns you have with any drugs that you are taking or are prescribed. He or she can discuss the choices you have and which drug may be right for you.
If you have any questions about your prescription drug benefits, call the number on the back of your ID card.