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Medical Benefit Drug Coverage

Some prescription drugs can be taken on your own. These are often covered under your pharmacy benefits. Other prescription drugs are given by a provider, like a doctor or nurse, in a clinic, hospital, or office. These drugs may be covered under your medical benefits rather than your pharmacy benefits.

Starting 9/1/2026, medical coverage for certain medications may require you to:

complete step therapy
get treatment at an approved site of care

These coverage requirements are outlined in your TRS-ActiveCare plan. Call 1-866-355-5999 or chat with a Personal Health Guide in the BCBSTX App or review your benefits booklet for more details.

Drug lists may change frequently. Get the latest information below.

Coverage Requirements and Affected Drug Lists

Step Therapy

Step therapy means you may need to try one or more drugs before another drug is covered. It’s part of your TRS-ActiveCare plan design, not a medical decision about what you need. Your coverage may depend on completing the steps.

Review the list of Medical Benefit Drugs with a Step Therapy Requirement for details.

Site of Care

Some medications covered under your TRS-ActiveCare plan have site of care requirements. These medications are usually given by infusion or injection. Site of care defines where a medication is given, not if it’s appropriate for your treatment.

Coverage for these drugs is usually available in lower-cost outpatient settings, such as:

provider’s office
specialty clinic
freestanding infusion center
home infusion (when available)

You may pay more if the drug is given at a non-preferred location. Hospital outpatient settings may not be covered for some medications unless you get an exception. If a hospital setting is approved, it only applies to where the drug is given, not if the drug is covered.

Check the Site of Care Drug List for details.

What if Your Medication is on the List?

These requirements are health plan coverage rules. They don't determine coverage of the medication itself. Your provider may need to request a prior authorization, or pre-approval, for coverage of the medication.
Talk to your provider about your treatment options.
Your provider can ask for an exception by completing one of these forms:
- Site of Care Medication Administration Exception form
- Step Therapy Benefit Exception form

Have Questions?

For more information about medical benefit drugs, coverage limitations or your benefits, call a Personal Health Guide at 1-866-355-5999 or chat through the BCBSTX App.