Understanding BCBS Drug Formulary 2023

The Blue Cross Blue Shield (BCBS) drug formulary 2023 is a list of prescription medications that are covered by BCBS health insurance plans. This list is crucial for patients to know which medications are covered and which are not.

BCBS maintains a comprehensive formulary to ensure that patients have access to necessary medications while also controlling costs. The formulary is regularly updated to reflect new medications and changing medical guidelines.

Each medication on the formulary is classified into a specific tier based on its cost and clinical effectiveness. Tier 1 medications are typically the most cost-effective and are often preferred by patients and healthcare providers.

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Medicare and Medicaid Plans offer prescription drug coverage options. Medicare Part D Individual and Employer Group Plans are available, but it's essential to learn about their prescription drug formularies.

Medicare Part D Individual and Employer Group Plan prescription drug formularies can be found by clicking a link. This provides valuable information for those seeking coverage.

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Medicare Part D Plans offer prescription drug coverage to Medicare beneficiaries.

Medicare Part D Individual and Employer Group Plans are available to those who want to purchase prescription drug coverage.

You can click a link to learn about Medicare Part D prescription drug formularies, which are lists of covered medications.

Medicare Part D prescription drug formularies are an important consideration when choosing a plan.

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Medicaid members enrolled in Blue Choice Option, HMO Blue Option, and Blue Option Plus will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program, starting April 1, 2023.

This transition affects those enrolled in these plans and will impact how they access and pay for prescription medications.

NYRx is the Medicaid Pharmacy Program that will handle prescription drug benefits, providing a new system for members to manage their medication needs.

Members and providers can find more information about NYRx, including general information and additional resources, on the NYRx website.

The pharmacy benefit transition from Blue Choice Option, HMO Blue Option, and Blue Option Plus to NYRx will require some adjustments for those affected.

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If you're looking for individual and family plans, you have options for plans with 1-100 employees. These plans are designed for small businesses and self-employed individuals.

Medicare Advantage plans can be used for these types of plans, and they often include Part D prescription drug coverage. Some plans also offer dental, vision, and hearing coverage.

For individuals, you can choose from a range of plan options, including HMO and PPO plans. These plans often have lower premiums than traditional Medicare plans.

Many plans also offer additional benefits, such as gym memberships or meal delivery services. These benefits can be a great perk for individuals and families looking for a comprehensive health plan.

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Your BCBS formulary is a list of covered prescription drugs, carefully selected by a group of independent doctors and pharmacists based on their effectiveness, safety, and value. They consider factors like generic and brand-name options to ensure you get the best treatment at a lower cost.

A generic drug is usually the most affordable option, and you should always consider it if your doctor says it's right for you. If a generic isn't available, a preferred brand-name drug is the next best choice.

Different formularies may cover different drugs, place drugs at different copayment tiers, or have different management programs. If you're unsure which applies to you, speak with your human resources department or refer to your benefit document.

Each drug in the formulary is assigned a tier under your benefit plan, and each tier is associated with a copayment or coinsurance amount. Here's a breakdown of common tier groupings:

Specialty medications are used to treat complex or chronic medical conditions like cancer, rheumatoid arthritis, multiple sclerosis, and hepatitis. You may pay a different copayment or coinsurance for specialty drugs under the pharmacy benefit.

Some members are subject to separate management programs for specialty drugs that are covered under their medical benefit. These programs may require prior authorization for certain medical specialty drugs, and some infused specialty drugs must be administered at a specific site of care, such as at home or at an infusion suite.

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Certain self-administered specialty drugs are only covered under the pharmacy benefit. You can find more information on these programs by checking the Medical Drug List and Self-Administered Drug List.

If you're prescribed a maintenance drug, you may be able to fill your prescription for 90 days at a time. Some health plans require 90-day fills for maintenance drugs, so be sure to check your member guide for details.

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Our pharmacy committee regularly reviews medications to ensure they're safe, effective, and cost-effective. They may decide to no longer cover certain drugs if alternatives are available.

The committee moves these drugs to nonformulary status, which means they're not covered by our plan. This decision is made to promote the use of more affordable options.

Some plans, including ours, may exclude coverage for certain categories of drugs, such as those for weight loss, fertility, or sexual dysfunction. You and your doctor always have the freedom to choose the medication that works best for you.

You can find more information about nonformulary and excluded drugs by following the link provided.

Specialty medications are prescription drugs used to treat complex or chronic conditions like cancer, rheumatoid arthritis, multiple sclerosis, and hepatitis.

These medications often require a different copayment or coinsurance under the pharmacy benefit, depending on your plan.

Some members may be subject to separate management programs for specialty drugs covered under their medical benefit.

Certain medical specialty drugs, such as injectable or infusible ones, require prior authorization.

Infused specialty drugs must be administered at a specific site of care, like at home or at an infusion suite.

Self-administered specialty drugs are only covered under the pharmacy benefit.

Here are some resources to help you navigate specialty medications:

If you have self-administered specialty medications, you may need to purchase them from a participating specialty pharmacy to receive coverage under your prescription drug benefit.

Maintenance medications are prescription drugs you take on a long-term basis, often to treat a chronic condition. They can be filled for 90 days at a time, and some health plans require 90-day fills.

You can check your member guide for details on your specific plan's requirements. I've found that having a clear understanding of my own plan's rules helps me stay on top of my medication schedule.

Some benefit plans require certain medications to be purchased through mail order or home delivery pharmacies. If you're unsure about your plan's requirements, it's a good idea to check your member guide or contact your plan administrator for clarification.

Here are some examples of medications that may require mail order or home delivery: Medications Requiring Mail Order or Home Delivery ServiceOpen a PDFNational Preferred Formulary - Medications Requiring Mail Order or Home Delivery ServiceOpen a PDF

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