BCBS Prescription Coverage Explained - Plans and Benefits

Blue Cross Blue Shield (BCBS) offers various prescription coverage plans that cater to different needs and budgets.

BCBS has several types of plans, including Standard, Enhanced, and Value, each with its own set of benefits and copays.

The Standard plan has a lower premium but higher copays, while the Enhanced plan has higher premiums but lower copays.

BCBS prescription coverage includes a 30-day supply of medication, with some plans offering a 90-day supply.

Copays for generic medications typically range from $10 to $30, while copays for brand-name medications range from $30 to $50.

BlueRx Plans offer a wide reach with 63,000 pharmacies nationwide. This makes it convenient for you to get your prescriptions filled.

You can also take advantage of their mail-order pharmacy service. This can be a great option if you need to fill a prescription that's not readily available at a local pharmacy.

The plans include a $0 deductible option, which can save you money upfront. You can also save 33% on prescription drug costs by using standard cost-sharing pharmacies.

BlueRx Plans offer a wide range of benefits that can help you save money on prescription medications.

With 63,000 pharmacies nationwide, you'll have plenty of options to choose from when it's time to fill your prescription.

You can also take advantage of BlueRx's mail-order pharmacy service, which can be a convenient option for those who prefer to have their medications delivered to their doorstep.

Prescriptions as low as $0 is a significant perk, especially for those who take regular medications.

There are also options to save 33% on prescription drug costs at standard cost-sharing pharmacies.

You have three plan options to choose from, so you can pick the one that best fits your needs and budget.

Here's a quick rundown of the pharmacy options available with BlueRx Plans:

If you're looking for a low-cost option, the BlueRx Essential plan is a good choice. It has the lowest monthly premium among all the BlueRx plans.

One of the benefits of BlueRx Essential is that it has a $590 deductible, which is a relatively standard amount. This means you'll need to pay this amount before your insurance kicks in.

You'll also appreciate that copays can be as low as $0, depending on the pharmacy you use. Standard Cost-Sharing Pharmacies are part of this plan, which can help you save money on prescription medications.

Keep in mind that you'll still need to pay your Medicare Part B premium, unless you're covered under Medicaid or another third-party plan.

BlueRx Enhanced Plus offers a low deductible of $50 for individuals and $100 for families, making it a great option for those who want to minimize their out-of-pocket costs.

This plan has a maximum out-of-pocket (MOOP) of $6,000 for individuals and $12,000 for families, which is higher than the standard BlueRx Enhanced plan.

With a 25% coinsurance after the deductible, you'll pay a lower percentage of the medication cost as you reach the deductible threshold.

The BlueRx Enhanced Plus plan covers a wide range of medications, including brand-name and generic options, and has a $3 copay for Tier 1 medications.

For those with Medicaid, it's worth noting that Blue Choice Option, HMO Blue Option, and Blue Option Plus will be transitioning to NYRx, the Medicaid Pharmacy Program, starting April 1, 2023.

NYRx will be handling all prescription drug needs for these Medicaid members, replacing the previous pharmacy benefit.

If you're a Medicaid member enrolled in one of these plans, you'll want to learn more about the transition and how it affects you.

Medicare D-SNP plans are a type of Medicare plan that combines Medicare and Medicaid benefits. They're designed for people who are eligible for both Medicare and Medicaid.

These plans can be a great option for individuals who have complex health needs, as they often have lower out-of-pocket costs and more comprehensive coverage.

To find the right D-SNP plan for you, it's essential to check your plan's formulary, which lists the medications covered by your plan. You can do this by visiting your Medicare member's website and clicking on the "Check Drug Lists" tab.

Medicaid Managed Care is a program that helps those with certain health insurance options get the care they need.

Beginning April 1, 2023, all 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.

Medicaid members with these options will no longer receive their pharmacy benefits through Blue Choice Option, HMO Blue Option, and Blue Option Plus after April 1, 2023.

To learn more about the transition of the pharmacy benefit, you can access general information about NYRx, the Medicaid Pharmacy Program, along with additional information for Members and Providers.

Your prescription drug benefit is based on a list of covered drugs called a formulary, which is chosen by a group of independent doctors and pharmacists based on effectiveness, safety, and value.

A formulary, also known as a drug list, is a list of brand-name and generic drugs that are covered under your prescription drug benefit.

If you want to save the most on your drug costs, ask your doctor if a generic or preferred brand-name drug is right for you.

Mail-Order Pharmacy Service is a convenient option for getting your routine medication without leaving home. You can get up to a 100-day supply by mail and pay only the copay for a 60-day supply.

This means you'll get one month of medication for free, along with free standard shipping.

The BlueRx Essential (PDP) plan offers prescriptions as low as $0, with a copay of $17.50 for a 100% LIS (Low-Income Subsidy) plan.

Your prescription drug benefit is based on a list of covered drugs called a formulary. A group of independent doctors and pharmacists chooses the drugs for our formularies based on their effectiveness, safety, and value.

If you want to save the most on your drug costs, ask your doctor if a generic or preferred brand-name drug is right for you. This can make a big difference in your out-of-pocket expenses.

Different formularies may cover different drugs, place drugs at different copayment tiers, or have different management programs. Speak with your human resources department or refer to your benefit document if you're not sure which applies to you.

You can find more information about your formulary by contacting Customer Care using the number on the back of your member card. They can answer any questions you have about coverage, pricing, or rules.

Here's a quick rundown of what you need to know about formularies:

Remember, your doctor always has the freedom to choose the medication that works best for you, even if it's not on your formulary.

Generic drugs are available when patents expire on brand-name drugs. They contain the same active ingredients as brand-name drugs but are not manufactured under a brand name or trademark.

The color and shape of the generic drug may be different from its brand-name counterpart, but the active ingredients are the same for both. Generic drugs must meet the same U.S. Food and Drug Administration quality standards as the brand-name drugs.

Some members have a Dispense as Written generic program as part of their prescription drug benefit. This means if a member has a prescription for a particular brand-name drug that is also available in generic form, he or she will pay more for that brand-name drug if he or she opts to fill it instead of the generic version.

If your doctor feels that the generic version is not appropriate for you, he or she can request an exception detailing why the member must have the brand-name drug over the generic version.

To get the most out of your BCBS prescription coverage, it's essential to understand how pricing and tiers work.

You can use the Drug Price Estimating Tool to find out how much you'll pay out-of-pocket for a specific drug, plus lower cost options if available. This tool can be a huge help in planning your medication expenses.

Each drug in the formulary is assigned a tier under your benefit plan, and each tier is associated with a copayment or coinsurance amount. You can find the specific amounts that apply to you by referring to your benefit document.

Here's a quick rundown of common tier groupings:

The $0 Deductible Option is a great choice for those who want to minimize their upfront costs. BlueRx ENHANCED PLUS offers this option, with a $0 deductible and a monthly plan premium of $129.30.

Pricing can be a major concern for those taking prescription medications. The cost of a specific drug can vary significantly, and it's essential to have an idea of what to expect.

The Drug Price Estimating Tool can help you estimate the out-of-pocket cost for a particular drug, and it may also provide lower cost options if available.

OneTouch is an independent organization that offers discounted products to members of Blue Cross and Blue Shield of Rhode Island, providing a potential solution for those looking to reduce their medication expenses.

Tiers are a way to categorize drugs under your benefit plan, with each tier associated with a specific copayment or coinsurance amount. This amount is what you pay when you get a prescription.

You should always consider generic drugs for the lowest out-of-pocket expense, as they are assigned to the lowest tier. In fact, generic drugs are often the best option for saving money.

Preferred brand-name drugs are the next tier up, and are a good choice if no generic drug is available to treat your condition. These drugs are often less expensive than nonpreferred brand-name drugs.

Nonpreferred brand-name drugs are usually the highest-cost products, and often move to this tier when a generic becomes available. This means that if you're taking a brand-name drug, it's worth checking if a generic version is available.

Most plans have one or more tiers designated for specialty drugs, which are often more expensive than other types of medications.

Management Programs are in place to ensure you get the most out of your BCBS prescription coverage. This includes Prior Authorization, which requires approval for certain drugs, and Quantity Management, which limits the amount of certain drugs covered.

Most members need prior authorization for certain drugs, so be sure to check with your human resources department or benefit document to see which ones apply to you. This can help prevent unexpected costs down the line.

You may also be required to try one or more Step 1 drugs before your plan will cover Step 2 drugs, as part of the Step Therapy program. This can be a good opportunity to explore alternative treatments that might work just as well for you.

We've implemented an opioid management program to help combat the national opioid crisis. This program is based on guidelines from the U.S. Centers for Disease Control and Prevention.

Daily quantity limits are in place for each covered opioid drug, ensuring that members receive a safe and controlled amount of medication.

Prior authorization requirements are necessary for certain prescribing situations to prevent misuse and overuse of opioids.

For first-time prescriptions, we limit the amount of opioid medication we will cover to prevent excessive use from the start.

Most of our members need prior authorization for certain drugs, so it's essential to check with your human resources department or benefit document to see which ones apply to you.

Prior authorization can be a hassle, but it's in place to ensure you're getting the right medication for your needs.

Certain drugs require prior authorization, and it's not uncommon for this process to take a few days or even weeks.

Quantity Management limits the amount of certain drugs your plan will cover, which can be a good thing if you're prone to overusing medication.

If you're unsure about which programs apply to you, refer to your Schedule of Benefits or speak with your human resources department.

Here's a quick rundown of the programs mentioned:

Excellus BCBS offers a range of management programs to help you stay on top of your health care needs.

The Medication Assurance Program and Drug List is available, which can be accessed by opening a PDF.

This program is applicable to commercial groups, individuals, and families who purchase their health plan on their own from NY State of Health or directly from Excellus BCBS.

The Patient Assurance Program and Drug List is also available, which can be accessed by opening a PDF.

A Contraceptive List is available for plans without Prescription Drug coverage, and can be accessed by opening a PDF.

This list is specifically designed for plans without Prescription Drug coverage.

The Preventive Drug List is available for select HDHP plans, and can be accessed by opening a PDF.

The Preventive Drug List - National Preferred Formulary is also available for select HDHP plans, and can be accessed by opening a PDF.

This list is specifically designed for select HDHP plans.

Preventive drugs can help you live a healthier life today and avoid serious illness in the future, as directed by your doctor.

Taking preventive drugs as prescribed may help prevent serious illnesses and complications. These drugs are often covered at $0 cost to members under health care reform, thanks to the Affordable Care Act.

You can talk to your benefits coordinator to learn if your plan offers this benefit, which can be a huge help in managing your health.

Managing diabetes requires monitoring your blood sugar levels, and using a reliable blood glucose meter is crucial for that. OneTouch products are preferred on our formulary, which can help you save money.

You can get a new OneTouch meter at no cost to you if your doctor agrees to the switch. Just print the voucher and take it to a network pharmacy along with your member ID card.

Your doctor will need to write you a prescription for your new OneTouch test strips. All other test strips are nonpreferred and require prior authorization.