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Medical Benefit Drug Coverage

Some prescription drugs can be taken on your own. These are often covered under your employee's 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 medical benefits rather than their pharmacy benefits.

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

complete step therapy
get treatment at an approved site of care

These coverage requirements are outlined in their TRS-ActiveCare plan. They can call 1-866-355-5999 or chat with a Personal Health Guide in the BCBSTX App or review their 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 participants may need to try one or more drugs before another drug is covered. It’s part of their TRS-ActiveCare plan design, not a medical decision about what they need. Their 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 participants 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 their 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)

Participants may pay more if the drug is given at a non-preferred location. Hospital outpatient settings may not be covered for some medications unless they 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 Their Medication is on the List?

These requirements are health plan coverage rules. They don't determine coverage of the medication itself. Their provider may need to request a prior authorization, or pre-approval, for coverage of the medication.
Participants can talk to their provider about their treatment options.
Their 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 benefits, participants can call a Personal Health Guide at 1-866-355-5999 or chat through the BCBSTX App.