Your prescription drug coverage is one of the most important parts of your health plan. Learn about your benefits, see which drugs are covered by your plan, and explore programs and resources that can help you save money.
Show your Capital Blue Cross member ID card at any in-network pharmacy when you have a prescription to fill. You can find in-network pharmacies by logging in to your secure account. Your plan’s benefits determine if or how much you are charged when you pick up your medication. Note that 75 percent of your previous supply must be used before you can get a refill.1
Enjoy the convenience of having prescriptions delivered straight to your home. Express Scripts® Pharmacy is your plan’s home delivery pharmacy and makes it easy to get the drugs you need to be your healthiest.
When ordering a 90-day supply or refills of a prescription drug through home delivery:
- Be sure your provider indicates 90-day supply and the number of refills you need on your written prescription.
- 60 percent of the previous supply must be used before a refill is sent.
- Allow up to 14 days for delivery and have at least two weeks of medication on hand when ordering any refills.
You can set up auto-refills so you can conveniently continue receiving your medications at home until you have either used all of your refills or your prescription expires. You will need to set up auto-refills each time your provider writes a new prescription for you, even if it is for a drug you have ordered before.
Orders totaling $250 or less will be charged to the payment method on file with Express Scripts Pharmacy. If your order is more than $250 and this is the first time filling for this medication at this copay amount, you will receive communication from Express Scripts Pharmacy requesting approval to process the prescription. This communication will be a text message, email, or phone call depending upon how you have set up your communication preferences with Express Scripts Pharmacy. Your prescription will be on hold until you respond to the pharmacy. Express Scripts Pharmacy will attempt to call you one time for payment authorization. If they are unable to reach you or you do not return their call after one attempt, your order will be canceled.
Which drugs does my plan cover?
Your formulary is a list of drugs covered by your health plan. Capital Blue Cross manages the formulary by including generic and brand-name prescription drugs that focus on your safety and help you save money. Every drug listed on the formulary has been approved by the U.S. Food and Drug Administration (FDA), which means they have been carefully tested and meet strict safety standards.
Generic drugs are typically the most affordable and offer a lower cost share than brand-name drugs. The active ingredient in a generic drug is chemically identical to the active ingredient in the brand-name version. To help lower your out-of-pocket costs, choose generic drugs whenever possible. Your formulary may classify generic drugs into two categories: generic preferred and generic nonpreferred. The difference between the two is their cost—generic preferred drugs typically cost less than generic nonpreferred drugs. Note, however, that generic nonpreferred drugs usually cost less than brand-name drugs.3
Brand-name drugs are marketed and sold under a specific trade name and are protected by a patent. Your formulary may classify brand drugs into two categories: preferred and nonpreferred. Brand preferred drugs usually cost more than generics but normally cost less that other brand drugs that treat the same condition. Brand nonpreferred drugs usually have the highest cost share and receive their label because they have not been found to be more cost effective than available generic, over-the-counter, or preferred brand drugs.
Prior Authorization4
This process encourages medically appropriate and cost-effective use of certain drugs. You can easily find these drugs on your formulary.
To help prevent possible delays in filling prescriptions that require prior authorization, you or your provider should request prior authorization before your prescriptions are filled. Your benefits will not cover prescription drugs that require prior authorization until the authorization is secured.
Your in-network provider will request prior authorization for you. You can also start a prior authorization request by calling the Member Services number on your member ID card or by logging in to your secure account. You will need:
- Your name (as it appears on your member ID card)
- Your member number
- Your date of birth
- Name of the drug
- Name of the provider who prescribed the drug
- Prescribing provider’s phone number
- Prescribing provider’s fax number (if available)
If your authorization is not approved, you can still get your prescription; however, you will be responsible for the entire cost of the drug. You may appeal the decision or you may ask your provider to prescribe another drug that is covered by your benefits. Note that if your prescribing provider is not in Capital Blue Cross’ network, you are responsible for requesting prior authorization.
Enhanced Prior Authorization4 (Step Therapy)
Your plan includes a process called enhanced prior authorization for certain prescription drugs, which means you may be asked to try a different drug first. Your provider or pharmacist can call Capital Blue Cross at the phone number listed on your member ID card to start enhanced prior authorization. You can also start the process by calling the Member Services number on your member ID card or through your secure account.
Drug Quantity Management Program
Your plan also includes quantity limits for certain prescription drugs to support safety. These drugs will be noted on your formulary. If your prescription is written for more than the allowed quantity, your pharmacy will only fill up to the allowed amount. Your provider can request an exception to quantity limits by calling the number on your Capital Blue Cross member ID card.
Generic Substitution Program
Your benefits may include a mandatory or restrictive generic substitution program to help you save money and control drug costs. Under the mandatory program, your pharmacy may replace a brand-name drug with a generic one. If you request the brand-name one, you will be charged the brand-name cost share plus the cost difference between the generic and brand-name medication.
Under the restrictive program, your provider can write Brand Medically Necessary on your prescription. In this case, you will only be charged the brand-name cost share. However, if you request a brand-name drug when a generic is available, you will be charged the brand-name cost share plus the cost difference between the generic and brand-name medication. Check your plan highlight sheet or Certificate of Coverage to see if either program applies to your plan.
Specialty Drugs (self-administered)
Accredo3 serves as your plan’s specialty drug pharmacy. If you need a specialty drug to manage your unique health condition, a patient care coordinator from Accredo will work with a team of pharmacists, nurses, your provider, and us to give you personalized care that helps best manage your needs. Your services include:
- Help getting prior authorization and refills
- The convenience of having your drugs delivered directly to your home at no additional cost
- Free supplies, such as needles, syringes, and disposal containers
- Training and educational resources to help ensure you know how to take your medication
- Care management programs that can help you get the best results from our prescribed drug therapy
Accredo will call or email you once they receive your prescription or when it is time for a refill. To set up an account with Accredo, call 833.721.1626. or visit the Accredo website for more information.
Your Benefit Booklet (Certificate of Coverage) includes specific terms, conditions, exclusions, and limitations about your specialty drug benefits.
For more information about specialty drugs, call Accredo at 833.721.1626.
Pharmacy Networks
As a Capital Blue Cross member, you have access to thousands of retail pharmacies across the country, including many well-known chains (such as CVS, Rite Aid, Target, and Wal-Mart), grocery stores, and independent pharmacies. To help make sure you pay the lowest amount for your prescription drugs, use a pharmacy in your plan’s network. You can find in-network pharmacies by logging in to your secure account calling the Member Services number on your member ID card.
90DayMyWay®
If your plan includes this program, you must get your maintenance drugs in 90-day supplies. Remember to ask your provider to write a 90-day prescription. You can fill your 90-day prescriptions for maintenance drugs through home delivery or by picking them up at pharmacies that are part of the Extended Supply Network.
Some plans allow an initial 30-day fill and a 30-day refill for maintenance drugs before 90DayMyWay requires members to get 90-day fills. Check your Certificate of Coverage for details. Drug quantity level limits apply to all applicable generic equivalents of the brand-name products. Applicable home delivery quantity levels are two to three times the retail quantity level limits, depending on the prescription drug benefit design chosen by the member or employer group.
Extended Supply Network
This network includes pharmacies that are allowed to dispense prescriptions drugs in amounts up to 90 days. Most of the popular retail chain and grocery store pharmacies are part of the Extended Supply Network. You can find which pharmacies are part of the Extended Supply Network by logging in to your secure member account or calling the Member Services number on your member ID card.
Log in to your secure account to manage your prescription drug benefits. See which drugs are covered by your plan (your formulary), find pharmacies, and learn more about your plan’s prescription drug programs in this one-stop shop. Also, your Member Services team is available 24 hours a day, seven days a week to answer your pharmacy benefit questions. You can call them at the number on your member ID card.
