Whether you take medication to manage an ongoing health condition or you need a prescription for an illness, you will want to become familiar with your health care plan's drug list. This is a list of covered drugs that are available to BCBSOK members.
Both brand and generic medications are included on the drug list. The drug list has different levels of coverage, which are called "tiers." Generally, if you choose a drug that is a lower tier, your out-of-pocket costs for a prescription drug will be less.
The drug list is not a substitute for the independent medical judgment of your health care provider. The final decision on what prescription drug is appropriate for you is between your health care provider and you.
You can view your drug list here. Be sure to choose the section that describes your plan.
When You Can Request a Coverage Exception
If your medication is not on (or has been removed) from your drug list, you or your prescribing doctor may want to request a coverage exception.
To request this exception, your prescribing doctor will need to send us documentation. To begin this process, you or your doctor should call the Customer Service number on the back of your ID card for more information.
You can also fill out and submit the Prescription Drug Coverage Exception form . You will need to provide us with your doctor’s name and contact information as well as the name and, if known, the strength and quantity of the drug being requested.
BCBSOK will usually let you or your doctor know of the benefit coverage decision within 72 hours of receiving your request. If the coverage request is denied, BCBSOK will let you know why it was denied and may advise you of a covered alternative drug (if applicable). You or your doctor may be able to ask for an expedited review if:
- You take medication for a health condition and failure to get that medication may either pose a risk to your life or health or could keep you from regaining maximum function
- Your current drug therapy uses a non-covered drug
If your review is expedited, BCBSOK will usually let you or your doctor know of the coverage decision within 24 hours of receiving your request. If the coverage request is denied, BCBSOK will let you know why it was denied and may advise you of a covered alternative drug (if applicable).
How to Request Reconsideration of a Drug Coverage Exception Determination
If your coverage request is denied, you may ask for an external review with an Independent Review Organization (IRO). To file an external review, fill out the external review request form and send to BCBSOK:
Submit your form to:
Blue Cross and Blue Shield of Oklahoma
P.O. Box 3283
Tulsa, OK 74102-3283
If you have a Multi-State Plan, you may ask for an external review with the U.S. Office of Personnel Management (OPM).
If your case qualifies for external review, OPM will review your case (including any data you’d like to add), at no cost to you, and make a final decision. To ask for an external review, you must first complete an External Review Intake Form . You have 1 year from the date you received the decision notice to file your external review request. See the OPM section in this notice for contact information.
You may file a request for External Review online or by mail. To file a request:
- Download and complete the External Review Intake Form
- Submit the forms to OPM by email at email@example.com, by fax at 1-202-606-0033, or mail them to:
MSPP External Review
National Healthcare Operations
U.S. Office of Personnel Management
1900 E Street, NW
Washington, DC 20415
You may call OPM toll free at 1-855-318-0714 if you need help with your request for External Review.
If you have any questions about requesting a coverage exception, call the Customer Service number on the back of your member ID card.