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Prescription Drug Information

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Prescription drugs are an important part of your health care coverage. If you have prescription drug coverage through Blue Cross and Blue Shield of Oklahoma (BCBSOK), we want to help you better understand your prescription drug coverage and options, including convenient services and any limitations. Here you'll find helpful information and forms you need.

This is only a brief description of some of the prescription drug benefits. Not all benefits are offered by all health plans. For more complete details, including benefits, limitations and exclusions, please refer to your benefit materials.



A prescription drug list, or formulary, is a list of preferred drugs available to BCBSOK members. These drugs are considered to be safe and cost-effective. Medications not listed on the formulary may require you to pay more out-of-pocket. Your BCBSOK prescription drug benefits may be based on the Standard Formulary or the Generics Plus Formulary. The Generics Plus Formulary is a smaller version of the Standard Formulary. It includes mostly generic drugs and also includes brand-name drugs. The Generics Plus Formulary covers all the major classes of drugs. Generic drugs usually cost less than brand-name drugs, and this saves money.

These drug lists are effective starting January 1, 2014.

View the Commonly Prescribed Maintenance Drug List  (These are drugs taken regularly for an ongoing condition)

If you're already a BCBSOK member, log in to Blue Access for MembersSM to learn more about your pharmacy benefits.


A prescription drug list, or formulary, is a list of preferred drugs available to BCBSOK members. These drugs are considered to be safe and cost-effective. Medications not listed on the formulary may require you to pay more out-of-pocket. Your BCBSOK prescription drug benefits may be based on the Standard Formulary or the Generics Plus Formulary. The Generics Plus Formulary is a smaller version of the Standard Formulary. It includes mostly generic drugs and also includes brand-name drugs. The Generics Plus Formulary covers all the major classes of drugs. Generic drugs usually cost less than brand-name drugs, and this saves money.

The formularies (list of preferred prescription drugs) below are used with BCBSOK health plans offered on and off the Oklahoma Health Insurance Marketplace. These can include Platinum, Gold, Silver, Bronze, Multi-State and Catastrophic plans. Your prescription drug benefits through BCBSOK may be based on either a Standard Formulary or a Generics Plus Formulary.

Metallic Individual Plans and Small Group (SHOP) Plans (group size 1–50 members)

Coverage begins January 1, 2014

Want to know which formulary your Marketplace plan uses? Check the charts below.

View the Commonly Prescribed Maintenance Drug List  (These are drugs taken regularly for an ongoing condition)

If you're already a BCBSOK member, log in to Blue Access for MembersSM to learn more about your pharmacy benefits.


If your health plan includes BCBSOK prescription drug benefits, these are administered by Prime Therapeutics, the pharmacy benefit manager (PBM).

Visit Prime Therapeutics  to:

  • Search for prescription drugs
  • Find a pharmacy
  • Order mail service refills or new prescriptions online
  • View status of coverage for your drugs
  • Download forms and brochures
  • Get drug cost estimates
  • Learn more about drug side effects or interactions

BCBSOK has a broad network of contracting pharmacies. To use your benefits, simply find a contracting pharmacy close to you and present your member ID card.


Comprehensive Prescription Drug Claim Form  (Updated 02/2009)


Prescription Drug Claim Form  (for Group Plan members) (Updated 01/2012)
BCBSOK members with pharmacy benefits through an employer group insurance plan can use this form to request reimbursement for a prescription drug purchase. You must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSOK pharmacy benefits manager.


Prescription Drug Claim Form  (for Individual Plan members) (Updated 01/2013)
BCBSOK members with pharmacy benefits through an individual insurance plan can use this form to request reimbursement for a prescription drug purchase. You must submit the original pharmacy receipt with the completed form to Prime Therapeutics, the BCBSOK pharmacy benefits manager.


Note: Blue Cross and Blue Shield health plans offered by self-insured employer groups may have different coverage options, plans or benefits. Please refer to your health plan contract, which governs eligibility, coverage exclusions and available benefits.


Your prescription drug coverage may include a specialty pharmacy program through Prime Therapeutics Specialty Pharmacy (Prime Specialty Pharmacy), which is part of our contracting pharmacy network. Specialty medications include those used in the treatment of complex medical conditions, such as hepatitis, hemophilia, multiple sclerosis, rheumatoid arthritis and other conditions requiring self-administered specialty medications.


Through Prime Specialty Pharmacy, members can have covered self-administered specialty medications delivered directly to them or their doctor's office. When you purchase specialty medications through Prime Specialty Pharmacy, you also receive at no additional charge the following services:

  • Coordination of coverage between you, your doctor and Blue Cross and Blue Shield of Oklahoma
  • Convenient delivery of medication to you or your physician's office
  • Educational materials about your particular condition and information about managing potential medication side effects
  • Syringes, sharps containers and other supplies with every shipment for self-injectable medications
  • 24/7/365 customer service phone access

View the Specialty Pharmacy Program Drug List , which includes a reminder about coverage for self-administered specialty medications.


View the Specialty Drug Flier 



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 booklet, or call the Pharmacy Program number on the back of your ID card.


Prior Authorization

Under this part of the program, your physician will be required to obtain authorization through Blue Cross and Blue Shield of Oklahoma in order for you to receive benefits for certain medications and drug categories.

  • 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 drug categories may be added and the medications listed are only examples. Call the Pharmacy Program 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.
Prior Authorization CategoryTargeted medications within category†*
Acne Solodyn
Androgens/Anabolic Steroids Anadrol-50, Androderm, Androgel, Android, Androxy, danazol, First-Testosterone, Methitest, Oxandrin, Striant, Testim, Testred
Antifungal Agents Lamisil, Noxafil, Penlac, Sporanox, Vfend
Enzyme Deficiencies Kuvan
Erectile Dysfunction Agents Caverject, Cialis, Edex, Levitra, Muse, Viagra
Hepatitis C Infergen, Pegasys, PegIntron
Narcolepsy Nuvigil, Provigil, Xyrem
Oral Fentanyl Actiq, Fentora, Onsolis
CAPS syndrome Arcalyst
Bone loss Forteo
Growth Hormones Genotropin, Humatrope, Norditropin, Nutropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Tev-Tropin, Zorbtive
Asthma Xolair

† Additional categories may be added and the program may change from time to time.

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


More information is available in the prior authorization member flier .


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 effective in treating a specific medical condition, as well as being a cost-effective treatment option.
  • A second-line drug is a less-preferred or potentially more costly treatment option.

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


Step 2: If your doctor determines that a first-line drug is not appropriate for you or is not effective in treating your condition, your prescription drug benefit will cover a second-line drug when certain criteria are met.


  • Below are 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 drug categories may be added and the medications listed are only examples. Call the Pharmacy Program 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 CategoryPrescription Drugs within the Category*
Attention Deficit Hyperactivity Disorder Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Dexedrine, Dextrostat, Focalin, Focalin XR, Intuniv, Liquadd, Methylin, Metadate CD, Metadate ER, Ritalin, Ritalin LA, Ritalin SR, Strattera, Vyvanse
Antidepressants (depression) Aplenzin, Celexa, Cymbalta, Effexor, Effexor XR, Lexapro, Luvox CR, Paxil, Paxil CR, Pexeva, Pristiq, Prozac, Remeron, Remeron SolTab, venlafaxine XR, Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zoloft
Cholesterol Advicor, Altoprev, Crestor, Lescol, Lescol XL, Lipitor, Mevacor, Pravachol, Simcor, Vytorin, Zetia, Zocor
COX-2 Inhibitor (pain relief) Celebrex
Diabetes Byetta, Victoza
Hypertension (high blood pressure Accupril, Accuretic, Aceon, Altace, Atacand, Atacand HCT, Avalide, Avapro, Azor, Benicar, Benicar HCT, Capoten, Capozide, Cozaar, Diovan, Diovan HCT, Exforge, Exforge HCT, Hyzaar, Lexxel, Lotensin, Lotensin HCT, Lotrel, Mavik, Micardis, Micardis HCT, Monopril, Monopril HCT, Prinivil, Prinzide, Tarka, Tekturna, Tekturna HCT, Teveten, Teveten HCT, Twynsta, Uniretic, Univasc, Valturna, Vaseretic, Vasotec, Zestoretic, Zestril
Insomnia Ambien, Ambien CR, Edluar, Lunesta, Rozerem, Sonata, Zolpimist
Multiple Sclerosis Avonex, Copaxone, Rebif, Betaseron, Extavia
Osteoporosis Actonel, Actonel with calcium, Boniva, Fosamax, Fosamax plus D
Proton Pump Inhibitors AcipHex, Dexilant (Kapidex), Nexium, pantoprazole
(control stomach acid production Prevacid, Prilosec, Protonix, Zegerid
Rheumatoid Arthritis/Psoriasis Cimzia prefilled syringe, Enbrel, Humira, Kineret, Simponi

† Additional categories may be added and the program may change from time to time.

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


More information is available in the step therapy member flier .


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


Right from your home, PrimeMail®, your mail order pharmacy, makes your health a top priority. With PrimeMail, ordering and receiving your long-term medications is easier than ever. PrimeMail provides safe, fast and cost-effective pharmacy services that can save you time and money without sacrificing quality or care. For more information and to start using the PrimeMail service, download these documents.

 

 


Learn more about generic drugs on the generics web page.

Vaccines can help protect you from illnesses such as the flu, pneumonia and shingles. If you have coverage through Blue Cross and Blue Shield of Oklahoma, vaccinations may be part of the medical benefit or prescription drug benefit, based on your plan.

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.
  • To see a complete list of all participating pharmacies, log in to Blue Access for Members and select Prescription Drugs from the Quick Links section on the right-hand side. Or, you can call the number on the back of your ID card.
  • Before you go, be sure to confirm your selected pharmacy's participation, hours and vaccine availability. Ask about any other age limits, restrictions or requirements that may apply. Remember to present your ID card to the pharmacist.

More information is available in the pharmacy vaccine program member flier .


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