To help you better understand your pharmacy coverage, here are answers to some frequently asked questions. If you don't find the answer you are looking for, please contact Member Service at the number on the front of your ID card.
Your doctor may request an exception from our Clinical Pharmacy Department to provide coverage for a non-covered drug when medically necessary. If approved, the drug will require the highest copayment level. If the request is not approved, you will remain responsible for the full cost of the prescription. You may use our standard member appeals process to request further review.
New ID cards are issued whenever benefits change. This might be the result of your employer's decision or a change in Massachusetts law. Your ID card contains valuable information, including phone numbers and copayment amounts, so be sure to read both sides carefully. Always carry your ID card with you to show your pharmacist or doctor.
Drugs generally require prior authorization in cases where the patient must meet certain medical-necessity criteria. For certain drugs approved by the Food and Drug Administration (FDA) and included on our covered drug list, we require the physician to obtain prior authorization before we reimburse the cost of the prescription drug. These drugs are listed in the formulary search. Patients must have pharmacy benefits under their subscriber certificates that cover those drugs that require prior authorization. Please see your plan sponsor for details.
On an ongoing basis our Pharmacy & Therapeutics Committee reviews the safety, effectiveness, and overall value of new drugs approved by the FDA. While a new drug is being reviewed, it will not be covered by your plan. This policy will not apply to members of our Medex®’ and Medicare HMO Blue® plans. As with other non-covered drugs, your physician may request coverage for a drug under review when medically necessary.
Blue Cross Blue Shield of Massachusetts relies on physicians practicing in Massachusetts to provide feedback on pharmacy program decisions. This committee, made up of representatives of physician organizations in Massachusetts, reviews drug comparisons for clinical benefit, side effects, and relative cost. The principle mission of the committee is to ensure that our members have drugs covered, or made available on an exception basis, that meet their needs and achieve desired treatment goals.
To check if a certain drug is under review and not yet covered, call the Member Service number on the front of your ID card.
PBMs, like the one we've partnered with, Express Scripts, Inc. are companies that specialize in administering prescription drug benefit programs. They also maintain an extensive retail pharmacy network to process your prescriptions. Because of their size, PBMs can negotiate discounted prices from drug companies.
Over the last two decades, the use of prescription drugs to treat illnesses ranging from allergies to heart disease has increased dramatically. With this development came greater demand for brand-name medications.
During the same period, legislation has allowed drug companies to extend their patents on brand-name drugs, which allows the drug maker to sell the drug exclusively for many years with limited competition.
Drug advertising regulations have loosened as well, spurring expensive marketing campaigns for brand-name drugs. These television and magazine ads have raised people's awareness of new drugs, resulting in a rapid increase in the number of requests for expensive, brand-name prescriptions.
No. Generic and brand-name drugs must meet the same FDA standards for safety, purity, strength, and effectiveness. The generic name of a drug is its chemical name. The brand name is the trade name under which the drug is advertised and sold. In general, generic drugs will save you money. So whenever possible, ask your doctor to prescribe generic drugs.
If you take medications on a regular basis, our Mail Service Pharmacy is a convenient way to save time and money. For most plans, you can order up to a 90-day supply through the mail, usually for the same amount you would pay for a 30-day supply at your local pharmacy. Plus, you can receive your medications through the mail, at home, or at work, postage paid, within 14 days of mailing your prescription.
In general, it's a good idea to plan ahead so that you don't have to worry about running out of your medications while on vacation. The first step is to get a prescription from your doctor for the amount of the medication needed.
If you're traveling within the U.S. and anticipate that your prescription will run out, ask your doctor for another prescription to take with you. You can fill your prescription at any participating pharmacy in the U.S. Our network consists of 94 percent of the pharmacies nationwide, including most major chains. To find a participating pharmacy in the area in which you'll be traveling, call Express Scripts Customer Service at 1-800-892-5119.
If you are traveling out of the country, your pharmacist will know how to obtain authorization for a special supply.
Yes. If you have a drug benefit you can fill your prescription at any participating pharmacy nationwide. Our network consists of 94 percent of the pharmacies nationwide, including most major chains. You can call the phone number on the front of your ID card to find a participating pharmacy near you.
Though you should always speak with your physician or pharmacist if you have any questions about prescription drugs, the Drug Search tool at AHealthyme.com can give you instant, up-to-date information on more than 4,000 prescription and over-the-counter drugs, including their interactions and side effects.
A formulary is a list of drugs covered by a health plan. Ours contains more than 3,500 drugs. It was developed by doctors and pharmacists after careful evaluation of clinical studies to determine which medications are most effective, safe, and maximize cost savings. Most plans, like ours, also maintain a small list of non-preferred drugs. The vast majority of the non-preferred drugs have one or more FDA-approved, covered alternatives. Our formulary allows us to offer you brand-name and generic drugs that meet your needs, at a reasonable cost.
Quality Care Dosing (QCD) is a program designed to ensure that the quality and dose of your prescription for certain medications meet FDA and other accepted clinical practice guidelines. In cases where it doesn't, QCD offers modifications to bring quantity and dosage in-line with FDA recommendations.