Prescription Drug Information
Get the most from your prescription drug coverage by using these helpful forms and documents to make changes, add features, file claims and much more.
Note: Forms on this page are available as PDF files. Just click on the appropriate form to view, download and print. You will need the Adobe® Reader® to access these files, which you can download for free at Adobe's site 
. If these downloadable PDF forms are altered in any way they will not be processed by Blue Cross and Blue Shield of Oklahoma.
Prescription Lists, Guides and Forms
Your prescription drug benefits through Blue Cross and Blue Shield of Oklahoma may be based on either the BCBSOK drug list or the generics plus drug list. How much you pay out-of-pocket for prescription drugs is determined by whether your medication is on this list. The drugs on this list are chosen based on many factors, including safety, effectiveness and cost.
View the BCBSOK Drug List 
View the Generics Plus List
If you're already a Blue Cross and Blue Shield of Oklahoma member, log in to Blue Access for MembersSM to learn more about your pharmacy benefits. You can locate a pharmacy, review the formulary, get an estimate of the cost of your medications, and learn about drug side effects and interactions.
Please refer to the following formulary updates summaries for drug list changes.
- View the BCBSOK Drug List Formulary Updates Summary
- View the Generics Plus List Formulary Updates Summary
Maintenance medications are drugs taken regularly for an ongoing condition. View the Blue Cross and Blue Shield of Oklahoma Maintenance Drug Listing (Updated 09/2010).
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
View more about our specialty pharmacy program from Prime Specialty Pharmacy 
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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 Category | Targeted 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 Category | Prescription 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.
- PrimeMail New Prescription Order Form (Updated 12/2010)
- PrimeMail Refill Prescription Order Form (Updated 12/2010)
- Tips for Ordering Prescription Drugs by Mail
