Here are some additional resources for your prescription drug coverage.
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Here are some additional resources for your prescription drug coverage.
The BCBSOK drug list, also known as a formulary, is a continually updated list of covered drugs. U.S. Food and Drug Administration (FDA)-approved drugs are chosen based on their safety, cost and how well they work. The drug list is reviewed by a group of doctors and pharmacists. This group makes routine updates based on new prescription drugs and other changes in the market. Members should show this list to their doctor and/or pharmacist. Health care providers should check the drug list when making prescription drug choices for you.
If a drug is not on the drug list, call the number on the back of your BCBSOK member ID card to see if the drug may be covered. Based on your benefit plan, you may have to pay more for a drug that is not on the drug list.
A generic drug is the same as a brand name drug in dose, strength, performance and use. Generics are also approved by the FDA. But generic drugs often cost less. Talk to your doctor or pharmacist about the choices you have and which drug may be right for you.
There are two types of generic drugs:
Examples of a brand drug and its generic equivalent:
Brand Drug-PROZAC || Generic Equivalent-fluoxetine
Brand Drug-LIPITOR || Generic Equivalent-atorvastatin
Your pharmacist can often substitute a generic equivalent for its brand counterpart without a new prescription from your doctor
Your doctor can decide if a generic alternative is right for you.
Some plans may require you to pay more if your doctor prescribes a brand drug when a generic equivalent is available. A generic equivalent is made with the same active ingredient(s) at the same dosage as the brand drug.
The prescription drug list has different levels of coverage, which are called "tiers." How much you pay out of pocket for a prescription drug is often less if you choose a drug that is a lower tier.
Your prescription drug benefit plan and whether the drug is on the drug list can determine the amount you may pay out of pocket.
To find out what you may pay, log in to Blue Access for MembersSM.
Some drugs may have limits on how much medicine can be filled per prescription or in a given time span. This is often based on the drug maker's research and FDA approval. If your doctor thinks you need more of a drug than what the dispensing limit allows, you can still get the drug. But you may be responsible for the full cost of the prescription, based on your benefit plan.
Specialty drugs are those used to treat rare or less common serious or chronic conditions. Examples are hepatitis C, hemophilia, multiple sclerosis and rheumatoid arthritis. These drugs often call for careful adherence to treatment plans, have special handling or storage needs and may not be stocked by retail pharmacies.
Some members may be required to use a select specialty pharmacy to fill these prescriptions to get the highest level of benefits.
View the Specialty Pharmacy Program Drug List which has a reminder about coverage for self-administered specialty drugs.
Certain drugs may require pre-approval, called prior authorization, to promote safe, cost-effective medication use. If your drug is part of this program, your doctor will need to submit prior authorization to use your benefits.
If the request is approved, you will pay for your share of the drug based on your benefit plan.
If the request is not approved, the drug will not be covered under your benefit plan. You can still fill your prescription, but you may have to pay the full amount, based on your benefit plan.
Check your benefit materials to see if your benefit plan includes prior authorization.
The Step Therapy program requires that you have a prescription history for a “preferred” or “first-line” drug before your benefit plan may cover a “non-preferred” or “second-line” drug.
Preferred drugs are safe and work well in treating a specific medical condition. They are also a cost-effective choice. A non-preferred drug is likely a more costly option.
Step 1: If possible, your doctor should prescribe a preferred drug right for your condition.
Step 2: If you and your doctor decide that a preferred medication is not right for you or is not as good in treating your condition, your doctor should submit a Step Therapy exception at bcbsok.com/provider.
Check your benefit materials to see if your plan includes Step Therapy. Review the member flier for more information about Step Therapy.
Some BCBSOK prescription drug benefit plans have a Member Pay the Difference Program. The program makes sure members use medicines that are safe, work well and are cost-effective. When you fill a prescription for a covered brand name drug when a generic equivalent is available, you may pay more.
Check your benefit materials to see if your benefit plan includes includes the Member Pay the Difference Program .
You should talk to your doctor or pharmacist about any questions or concerns you have with any drugs that you are taking or are prescribed. He or she can discuss the choices you have and which drug may be right for you.
If you have any questions about your prescription drug benefits, these programs and what drugs are covered, call the number on the back of your BCBSOK member ID card.
BCBSOK offers blood glucose meters to members with diabetes at no additional charge to help you manage your condition. See the glucose meter flier for more information about this offer and monitoring your blood glucose level.
Members with BCBSOK prescription drug coverage should check the Drug List to see which test strips for the meters offered are listed as preferred brands. Coverage and payment levels for test strips may vary based on your pharmacy benefit plan.
Last Updated: Oct. 01, 2024