Additional Resources

Here are some additional resources for your prescription drug coverage.

What is a drug list? 

The BCBSMT 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.

What if my doctor prescribes a drug that is not on the drug list (also known as a formulary)? 

If a drug is not on the drug list, call the number on the back of your BCBSMT 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.

What is a generic drug? 

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:

• A generic equivalent is made with the same active ingredient(s) at the same dosage as the brand drug

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

• A generic alternative is often used to treat the same condition, but the active ingredient(s) differs from the brand drug.

Your doctor can decide if a generic alternative is right for you.

Can I get a brand drug when a generic equivalent is available? 

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. 

How much will I pay for my medication? 

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 Members^SM.

What are dispensing limits?

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.

What is a specialty drug? 

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. 

What is Prior Authorization? 

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:

• Some benefit plans may require members to try a preferred medication before covering a non-preferred medication.
• Cost is only one factor in choosing medication. Treatment decisions are always between you and your doctor.
• Your doctor can find request forms at bcbsmt.com/provider.
• Review the member flier for more information about Prior Authorization.

What is Step Therapy?

The Step Therapy program requires a member's prescription history have a “preferred” medication before the benefit plan may cover the “non-preferred” medication.

Preferred medications are safe and work well in treating a specific medical condition. They are also a cost-effective choice.

Step 1: If possible, your doctor should prescribe a preferred medication 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 request a Step Therapy exception.

Check your benefit materials to see if your plan includes Step Therapy. Review the member flier for more information about Step Therapy.

What is the Member Pay the Difference Program? 

Some BCBSMT 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 .

Who can I contact for questions?

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 BCBSMT member ID card.

BCBSMT 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 BCBSMT 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.