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Guide to prescription

drug benefits

Your prescription drug coverage is one of the most important parts of your health plan.

Use this guide to understand how your benefits work, see which drugs are covered by your plan, and learn about programs and resources that can help you save money.

Explore your options

Retail pharmacies (local neighborhood or chain store pharmacy)

Show your 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

  • For most plans, in-network pharmacists will automatically submit a claim for you. You will be responsible for paying your cost share, according to your plan.2
  • If you go to an out-of-network pharmacy, you will need to send a completed pharmacy claim form along with your receipt to:
Pharmacy Services 
P.O. Box 25136 
Lehigh Valley, PA 18002-5136

Home delivery

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.3

  • Set up an account (including payment information) with Express Scripts® Pharmacy at 833.715.0946 or visit Express Scripts® Home Delivery. You can also log in to your secure account and choose "Start or Manage Home Delivery".
  • Ask your provider to send your prescription to Express Scripts Home Delivery. (Fax: 800.837.0959).
  • Continue managing your home delivery service (auto-refills, change in contact information, updated payment information, etc.) through your online account.

Tips and reminders for home delivery

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.

What drugs are covered

Your formulary is a list of drugs covered by your health plan. We manage 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.4

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.

Prescriptions drugs that aren’t listed on your formulary are not covered by your plan, unless approved through the nonformulary consideration (formulary exception) process. Your provider can submit a nonformulary consideration request on your behalf if they think you would benefit from a drug that’s not on your formulary.

Prior authorization

This process5 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 our network, you are responsible for requesting prior authorization.

Step therapy

Your plan includes a process called step therapy for certain prescription drugs, which means you may be asked to try a different drug first. Your provider or pharmacist can call us at the phone number listed on your member ID card to start step therapy. You can also start the process by calling the Member Services number on your member ID card or through your secure account.

Quantity level limit

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 doctor can request an exception to quantity limits by calling the number on your member ID card.

Special programs

Medication synchronization

You may obtain a partial fill or refill of your maintenance prescription drugs at your option when you are taking two or more maintenance medications. This can help make it easier for you to take medications correctly as prescribed. You can work with your in-network pharmacist, so that the refill syncs up with another maintenance medication. Additionally, we will prorate your applicable cost-share amounts (e.g., copay or coinsurance) to align with the reduced supply. You can initiate a synchronization up to three times per year. 

Split fill

To minimize waste and reduce your costs for certain pharmacy-dispensed specialty drugs that have a high potential for adverse side effects, we will “split fill” (i.e., partial fill) select specialty drugs for up to three months when you are new to treatment. New to treatment means, you receive a prescription of a select drug and have had no claims history of the drug in the past 120 days. The goal is to confirm effectiveness and tolerance before you receive a full supply.

  • Specialty drugs selected for this program are noted in the formulary and in the Guide to Prescription Drug Benefits. The select drugs are subject to change at Capital Blue Cross’ discretion.
  • You may call the phone number on the back of your member ID card or work with your pharmacist to opt out of this program and receive a full supply if you wish.
  • We will prorate your copays to align with the reduced supply.
  • Prior authorization and quantity limits may apply.

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 doctor 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 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 doctor 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.7

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.

Contact us

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.

1The amount of medication you can obtain at a retail or home delivery pharmacy depends on your drug benefit. Please refer to your Certificate of Coverage or policy.

2Some plans may require paper claim submissions to process reimbursements. Check you Certificate of Coverage for more information.

3Express Scripts® Pharmacy and Accredo are contracted through Prime Therapeutics LLC to provide mail pharmacy and specialty pharmacy services to members of Capital Blue Cross.

4Not all benefits include separate cost shares for generic preferred or generic nonpreferred drugs. For benefits that have one generic cost share for generic drugs, the cost share will be applied to all generic drugs. Refer to your Certificate of Coverage for specific information about your prescription drug benefit.

5Prior authorization and Step Therapy requests are processed as soon as possible once all information/documentation is received by Capital Blue Cross. For requests that meet predetermined clinical criteria, notification of approval will be communicated to the physician and to the member in writing. If prior authorization is denied, written notification, including the reason for the denial, will be sent to the member and the prescribing physician. In-network physicians and members have the right to appeal a denial. Appeal instructions are provided with the written denial notification.

6Your employer may opt out of this program. To check on your coverage, call the Member Services number on the back of your ID card for assistance.

7Some 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.

The information contained on this webpage was current at the time of publishing and is subject to change. It is not intended to substitute your physician’s independent medical judgement based on your specific needs. Please call the Member Services number on your ID card for the most current formulary information and your expected out-of-pocket costs.

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