Blue Cross and Blue Shield of Texas (BCBSTX) covers most of the prescription drugs that your Primary Care Provider (PCP) may think 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 approval ahead of time or have limits based on medical necessity. In these cases, your doctor must ask for approval before you get the drug.
You must get our approval 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, he or she 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. You can appeal the decision. Learn more about your appeal rights.
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 or if a brand-name drug is preferred by Medicaid.