bcbs Pharmacy Coverage and Benefits Explained

Blue Cross Blue Shield (BCBS) pharmacy coverage is designed to help you manage your prescription medication costs. BCBS offers a range of pharmacy benefits to its members.

You can fill your prescriptions at a network pharmacy or out-of-network pharmacy, but you'll pay more out-of-pocket if you choose the latter. Network pharmacies include retail pharmacies, mail-order pharmacies, and specialty pharmacies.

BCBS covers a wide range of prescription medications, including brand-name and generic medications. You can check your plan's formulary to see which medications are covered.

Understanding your pharmacy coverage is crucial to making the most of your benefits. You can use your pharmacy benefits to get discounts on medications and access a network of pharmacies.

To view your pharmacy claims history, including prescription number, date filled, prescriber, quantity, pharmacy, amount paid by you, and amount paid by your pharmacy plan, you must register to use Blueprint Portal, our member self-service center.

Your pharmacy plan may offer a network of pharmacies where you can fill your prescriptions at a lower cost. You can search for these pharmacies online.

Drug pricing can vary significantly, so it's essential to compare prices before filling your prescriptions. You can find information on drug pricing through your pharmacy plan.

To save money on medications, consider using generic medications or taking advantage of free immunizations at participating pharmacies.

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You can refill your mail-order prescriptions online, check the status of your mail order, and review your mail-order prescription history.

To get started, navigate to the pharmacy site on Blueprint Portal or download and complete the paper form.

To use Express Scripts Pharmacy, call 1-800-282-2881 (24 hours a day, 7 days a week) or use the Express Scripts mobile app.

Saint John Mail Order Pharmacy also offers standard shipping for free, for select prescriptions.

Here are the contact options for Express Scripts Pharmacy:

By connecting medical and pharmacy benefits, ASO groups can significantly lower their medical costs. A study by HealthScape Advisors tracked 6.4 million members for three years and found this to be true.

You can give employees more choices while retaining the benefits and availability of nearly all branded prescription drugs with prescription drug coverage. This is made possible through programs designed to simplify experiences and lower costs.

Here are some examples of individual and family drug lists that are available:

To manage your plan effectively, it's essential to understand your individual and family drug lists. You can access these lists through clinical documentation.

The lists include various formularies that cater to different plan types. For example, the 2025 Standard with Step Formulary 4 Tier is one option.

You can also choose from the 2025 Blue Choice Formulary, which is specifically designed for Blue Choice Plans. This formulary is tailored to meet the needs of these plans.

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Another option is the 2025 Complete Formulary, which is suitable for Complete/Complete Plus plans. This formulary provides a comprehensive list of covered medications.

If you have a Standardized plan, you can opt for the 2025 Metallic 5 Tier Formulary. This formulary is designed to meet the specific needs of Standardized plans.

Alternatively, you can choose the 2025 Metallic 6 Tier Formulary, which offers a more extensive list of covered medications.

Here's a summary of the individual and family drug lists:

National Networks can be a game-changer for your pharmacy benefits. By joining a national network, you can reduce pharmacy costs through purchasing power and discounts.

These discounts can lead to greater savings and improved access to medications for you and your employees.

You'll also have expanded access to pharmacies, including national and regional chains, as well as local independent pharmacies.

This gives you more choice and flexibility in where you fill your prescriptions. With a 30-day or 90-day supply option, you can choose the best plan for your needs and budget.

Here are some benefits of National Networks:

The Preferred Network is a great way to save money on your prescription medications. You can choose from hundreds of preferred pharmacies across the state, including big names like Walgreens, Walmart, and Costco.

To give you an idea of the scope, here are some of the preferred pharmacies you can use: WalgreensWalmartCostcoSam's ClubMany independent pharmacies

Using a preferred pharmacy can save you money on your Tiers 1-3 medications. Express Scripts mail-order pharmacy is also included in the preferred network, making it easy to get your medications delivered right to your door.

Tiers are a crucial part of your pharmacy plan, and understanding them can help you save money on prescription costs.

Each drug in the formulary is assigned a tier under your benefit plan, which determines the copayment or coinsurance amount you pay when you get a prescription.

You can find the tier amounts that apply to you in your benefit document.

There are four common tier groupings: generic, preferred brand, nonpreferred brand, and specialty.

Here's a breakdown of each tier:

By understanding the tier system, you can make informed decisions about your prescription medications and save money on your pharmacy costs.

Preventive Programs can make a big difference in your health and wallet. They help remove barriers to access and encourage adherence to medications, resulting in improved health outcomes.

Groups with High Deductible Health Plans (HDHP) can choose the HDHP-HSA and ACA Preventive Drug Programs. These programs provide benefits that can be a game-changer.

Preventive drugs are medications that may help prevent serious illnesses and complications. Taking them as directed by your doctor can help you live a healthier life today and avoid serious illness in the future.

Under health care reform, the Affordable Care Act requires most health plans to cover certain drugs at $0 cost to members. This can be a huge relief for those who need them.

IRS guidelines for high-deductible health plans provide that preventive care, including prescription medications used for preventive purposes, can be excluded from the deductible.

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Effective pharmacy management programs can significantly reduce costs for members. On average, these programs can save $516 per member per year.

To manage costs, Prime Therapeutics LLC, a pharmacy benefit management company, uses real-time medical and pharmacy data to drive down costs. This includes targeting medication adherence and utilization.

Some programs, like HighTouchRx, use claims data to identify opportunities for drug therapy optimization, resulting in significant savings.

Here are some examples of cost-saving programs:

Additionally, Blue Advantage works with Rx Savings Solutions (RxSS) to help members find the lowest-price options for their prescription medications, with some members saving up to $516 per year.

Most Medicare Part D plans require a monthly premium, which can vary in cost.

Some plans have deductibles, which are separate from the monthly premium and must be paid before insurance kicks in.

Many Part D plans require a fixed copayment each time you fill out a prescription, which can be a set amount like $10 or $20.

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Some Part D plans require a percentage (coinsurance) of a medication's cost every time you fill a prescription, which can be a percentage of the total cost.

The coverage gap, also known as the "donut hole", is a temporary limit where you are responsible for all of your drug costs until you reach the plan's annual out-of-pocket limit.

Beginning in 2025, Medicare Part D enrollees will have the option to pay their out-of-pocket Part D prescription drug cost in monthly amounts over the course of the plan year.

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Most Medicare Part D plans have "formularies", which are lists of covered prescription drugs. These formularies limit the types of medications your plan will cover.

Part D plans also have networks of approved pharmacies in your area. You'll need to stick to these pharmacies to get your prescriptions filled.

The specific drugs covered by your plan will depend on the formulary. Some plans may cover a wider range of medications than others.

To find out which pharmacies are part of your plan's network, check your Schedule of Benefits. This will also give you an idea of which drugs are covered under your plan.

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Effective programs target medication adherence, manage utilization, and leverage real-time medical and pharmacy data to drive down costs by an average savings of $516 per member per year.

Lowering costs doesn't have to mean sacrificing quality care. In fact, some programs can save you hundreds of dollars per year.

Prime Therapeutics LLC, a pharmacy benefit management company, helps drive down costs by managing pharmacy benefits and related services. They work with Blue Cross and Blue Shield Plans to provide personalized solutions.

One way to save money is by using the Drug Price Estimating Tool, which can help you find lower-cost options for your prescription medications.