Prescription and Pharmacy FAQs

Your prescription drug plan uses a drug list. It is a list of drugs based on the recommendations of a group of experts with a medical or pharmacy degree. They base their decisions on safety, cost and how well the drugs work. They review and update each list regularly. Each drug on the list is approved by the U.S. Food and Drug Administration.

If you’ve been told a prescription medicine isn’t covered, the first step is to find out more. Learn why the medicine is not covered. Ask the pharmacist. Check to see that it’s not a paperwork issue, like not getting pre-approval, also called prior authorization. Here's an article that may help or visit our Transparency in Coverage page.

Most drug lists have levels of coverage, called tiers. Each tier has its own cost. Your drug list may have up to 6 tiers. Often, your copayment or coinsurance amount is less for covered drugs in a lower tier. For example, brand drugs may be in a higher tier and their generic equivalent may be in a lower tier and cost you less.

There are a few ways to check if your medication is included in your drug list.

• The best way to check is to log in to your BAM account, click on the Pharmacy tab and search for a medication. You'll get information about that drug, including coverage and cost details.
• If you know the name of your plan or your drug list, you can find it here without logging in to BAM.
• You can talk to your doctor or pharmacist.

Some prescriptions need approval before your benefit plan covers them. Prior authorization helps make sure the drug is prescribed, managed, and taken safely.

If your drug is part of this program, your doctor will need to submit information first. If it’s approved, you will pay for your share of the drug based on your benefit plan. If it’s not approved, the drug will not be covered under your benefit plan. You can still get your prescription. But you may have to pay the full amount.

Treatment decisions are always between you and your doctor. Get our member flier for more details.

Most of the time, your pharmacist will notify you if a prescription needs prior authorization.  You can also log in to your BAM account , click on the Pharmacy tab and search for a medication. In the search results, information about that drug will appear, including if the drug needs prior authorization.

A team of experts reviews drugs that need prior authorization. The team is made up of doctors and pharmacists. They review the drug labels approved by the FDA. They also review scientific studies and national guidelines. They use this information to make informed decisions.

Mostly, your doctor must act. You can find information on the prior authorization process on our website. 

If it’s approved, you will pay your cost share for the drug based on your benefits. If it’s not approved, the drug will not be covered. You can still fill the prescription, but you will have to pay the full amount.

Cost is only one factor in choosing medication. As always, treatment decisions are between you and your doctor.

Dispensing limits are rules around the amount of a prescription drug you can fill at a pharmacy at one time. Limits are often based on the drug maker's research. You and your doctor may decide you need more of a drug than what the dispensing limit allows. In that case, you can still get the drug. But you may be responsible for the full cost of the drug based on your benefit plan.

If you log into BAM , click on the Pharmacy tab and search for your medication, it will give you details about that drug. If your medication has a dispensing limit, it will display.