BCBS PBM Pharmacy Benefits and Coverage Overview

Blue Cross Blue Shield Pharmacy Benefits Manager (PBM) plays a crucial role in managing pharmacy benefits and coverage for millions of BCBS members.

BCBS PBM uses a network of over 68,000 pharmacies to provide access to medications and other health services.

BCBS PBM's pharmacy network includes both retail and mail-order pharmacies, giving members the flexibility to choose how they receive their medications.

BCBS PBM's pharmacy benefits and coverage are designed to help members manage their medications and stay healthy.

BCBS PBM offers a range of pharmacy benefits and coverage options, including generic and brand-name medications, as well as specialty medications.

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A new year means a few changes to your BlueCross BlueShield of South Carolina prescription drug coverage. Beginning Jan. 1, 2020, the pharmacy benefit will be administered by a new pharmacy benefits manager (PBM) called OptumRx.

You'll receive a new ID card to use in 2020, which is a good idea to keep handy. Some members may experience additional changes to their prescription drug coverage on Jan. 1, as part of their health plan's regular pharmacy benefit updates.

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For most members, the changes will be minimal, and you won't notice a difference. However, if a drug you're taking will be moving to a higher tier on Jan. 1, you'll receive a letter to let you know.

The pharmacy benefit is based on tiers, which are the different cost levels you pay for medications.

So, let's talk about prescription drug coverage. Beginning Jan. 1, 2020, BlueCross BlueShield of South Carolina's pharmacy benefit will be administered by a new pharmacy benefits manager (PBM), OptumRx.

As of Jan. 1, 2020, the pharmacy benefit for BlueCross BlueShield of South Carolina will be administered by a new pharmacy benefits manager (PBM), OptumRx, which is an independent company that has been contracted to provide certain services related to your health plan's prescription drug coverage.

Your pharmacy benefit is based on tiers, and for most members, the drugs you take will stay at their current tier. However, from time to time, some drugs may move to a higher tier.

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If a drug you're taking will be moving to a higher tier on Jan. 1, we will send you a letter to let you know.

Here are some examples of medicines that are covered under your health plan:

Your doctor may prescribe medicines when you need them, as long as they are prescribed by a licensed health care professional, are medically necessary, approved by the Food and Drug Administration, and not excluded by the Michigan Medicaid program.

If you receive prescription medications through mail service, you're in luck because you can get up to a 90-day supply of your regular medications.

Mail service is a convenient option for many members, and with OptumRx Home Delivery taking over, you can expect a seamless transition. Beginning January 1, 2020, OptumRx Home Delivery will be providing mail service, and open prescription refills will be transferred from CVS Mail Service to the new pharmacy around the same time.

You don't need to do anything, as the transition will be handled for you.

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You can fill your prescriptions at a pharmacy that's part of our network, which includes almost 70,000 pharmacies, including all major chain pharmacies and most independent pharmacies.

If you're currently using a pharmacy that's not part of our new network, we'll send you a letter in December to inform you and suggest nearby pharmacies that are part of the network.

CVS pharmacies are included in our new national pharmacy network, so you can continue to use them if you're already a customer.

You can use the "Find a Pharmacy" locator to search for 2020 network pharmacies, starting October 15. This tool will help you find a pharmacy near you that's part of our network.

Our plan covers medicines that are prescribed by a licensed health care professional, medically necessary, approved by the Food and Drug Administration, and not excluded by the Michigan Medicaid program.

Some examples of covered medicines include sinus and allergy medicines, medicines to help you quit smoking, pain medicine, and heartburn medicine.

The following medicines are also covered:

If you're taking prescription medication, you'll be happy to know that your pharmacy benefit is based on tiers, which determine the cost level you pay for medications. Most members' drugs will stay at their current tier, but some may move to a higher tier.

Your doctor can prescribe medicines when you need them, as long as they're prescribed by a licensed healthcare professional, medically necessary, and approved by the FDA. They also cover medicines for conditions like sinus and allergies, smoking cessation, and heartburn.

You can get rid of unused medicines during National Prescription Drug Take Back Days in October and April. To find disposal locations near you, use the search tool provided.

If you're taking specialty medicines for complex diseases, you'll need to get prior authorization, which requires a completed Prior Authorization Request form. This form should be submitted according to the instructions on the form.

Here are some examples of medicines that are covered by your pharmacy benefit:

You can also get preferred diabetes monitoring supplies and insulin syringes and pen needles.

Prior authorization is a process that requires your doctor to submit a request to Blue Cross Complete before you can fill a prescription for certain medicines. Your doctor will need to use one of three tools to submit the request: CoverMyMeds prior authorization online portal, SureScripts prior authorization online portal, or a prior authorization request form (PDF).

The request must come from your doctor, not the pharmacist. They'll need to submit a request for prior authorization and an override of any drug restrictions.

If your doctor's request is denied, they can appeal the decision with your written approval. To do this, they'll need to write to Member Appeals at Blue Cross Complete of Michigan, P.O. Box 41789, North Charleston, SC 29423, or fax the request to 1-866-900-4482.

Here are the details for appealing a prior authorization denial:

Specialty medicines require prior authorization, which means you'll need to fill out a Prior Authorization Request form. This form must be submitted by following the steps on the form.

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All specialty medicines, such as those for complex diseases, require prior authorization. You can find the Prior Authorization Request form in PDF format.

Members 21 and older will pay a small fee for carve-outs, which include specialty medicines like those for HIV, hepatitis C, and cystic fibrosis. The copay is $1 for generic medicines and $3 for brand-name medicines.

Medicare and Medicaid can be a bit overwhelming, but let's break it down. You can talk with your doctor about generic versions or other drugs on your drug list that might work just as well.

If a drug you need isn't covered, your doctor can send a request to cover it if they feel it's important to your treatment. We'll consider the request and get back to you on our decision.

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