Including Prescription Medication Lists
This information applies only to Blue Cross® Blue Shield® of Arizona (BCBSAZ) customers
enrolled in a two tier brand and generic copay prescription plan. You can use the prescription medication
lists, at right, to learn more about the details of this standard benefit. If you
have questions about your prescription medication benefits, please refer to your
benefit plan booklet and benefit schedule page. You may also call (602) 864-4273
or (800) 232-2345, ext. 4273. Information is also available online to registered users of BlueNet Online Services.
Click here to register or learn more about BlueNet.
Tier Copays and Cost-Sharing for Prescription Medications
Prescription medications can be covered through several different plan benefits.
Coverage requirements and your cost-share obligations will vary, depending on the
applicable benefit and the supply source of the medication. Here, we explain how your
retail and mail order pharmacy benefit will work.
This retail and mail order pharmacy benefit has two cost-share levels (generic and
brand), which are listed on your schedule page. Cost-share is based on whether the
medication is brand or generic at the time the prescription is filled. Please use
a reference such as Drugs@FDA1
to serve as a guide to whether drugs are brand or generic.
In Network
For prescriptions obtained from an in-network retail pharmacy or the in-network mail
service pharmacy, you pay the lesser of the BCBSAZ price (the price for which BCBSAZ
has contracted with the pharmacy) or the applicable brand or generic medication costshare.
If the pharmacy's standard retail price for the prescription is less than both of
these amounts, the pharmacy may elect to charge you their lower price. You should
never pay more than your plan cost-share when you use in-network pharmacies, with
one exception. When you ask the pharmacy to fill your prescription for a brand product,
and your prescribing provider has approved an available generic version, you may be
responsible for the cost difference, in addition to your standard cost-share.
Check your benefit plan and schedule page for your out of network cost-share
responsibilities.
Out of Network
If your plan has an out-of-network pharmacy benefit, and you fill a covered prescription
at an out-of-network pharmacy, you must pay for your prescription in full and submit a
claim to BCBSAZ. When BCBSAZ processes your prescription claim from an out-of-network
pharmacy, and you qualify for covered benefits, BCBSAZ will reimburse you
based on the BCBSAZ allowed amount for the medication, minus any applicable cost
share portion. In addition to your cost share, you will be responsible for the difference
between the pharmacy's billed charges and the BCBSAZ allowed amount. Click here for
the Prescription Medication Reimbursement Form.
Retail and Mail Service Pharmacy Network
Click here to view a list of participating network pharmacies with BCBSAZ. This list is
subject to change at any time without prior notice. If your plan does not have out-ofnetwork
pharmacy benefits, you must use network pharmacies except in emergencies,
or your prescription will not be covered.
Precertification for Retail and Mail Service Pharmacy Benefits
Precertification is required for certain medications, including some medications covered
through the Retail and Mail Service Pharmacy Benefits. Please click here for a list of
prescription medications that require precertification. Click here to view the form that
prescribing providers may use to request precertification for Retail and Mail Service
Pharmacy Benefits. The list of medications that require precertification is subject to
change at any time without prior notice.
If precertification is required, but you must obtain the covered medication outside of
BCBSAZ precertification hours, the pharmacy may require you to pay for the medication
when it is dispensed. In those cases, you may send BCBSAZ a claim for reimbursement.
BCBSAZ will not deny such claims for lack of precertification, but will apply all other
exclusions and limitations of your benefit plan.
Prescription Medication and Vaccine Limitations for Retail and Mail Service Pharmacy Benefits
BCBSAZ applies limitations to certain prescription medications and vaccines obtained through the
retail and mail service pharmacy benefit. These limitations include, but are not limited to,
quantity, age, refill, and gender limitations. BCBSAZ prescription medication and vaccine limitations
are subject to change at any time without prior notice. Click here for a list of prescription
medications and vaccines subject to BCBSAZ prescription medication and vaccine limitations for Retail and Mail
Service Pharmacy Benefits.
For certain prescription medications, BCBSAZ applies a per-copay quantity limitation.
Members pay an additional copay each time the prescribed quantity exceeds the
BCBSAZ per-copay quantity limitation. If your provider prescribes more than the percopay
quantity limitation, you may buy the prescribed amount up to any refill limit, but
you will have to pay an additional copay each time you exceed the quantity limitation. If
the prescribed quantity is above the BCBSAZ maximum quantity for a 30-day supply
(retail) or 90-day supply (Mail Service), refill limitations will also apply. Prescription
medication refills are covered when approximately ¾ of the medication is used as
prescribed.
More Information About Your Retail and Mail Order Pharmacy Benefits
No exceptions will be made concerning the cost-share that will apply, regardless of the
medical reasons requiring use of a particular medication. This means if you are taking a
brand medication, you pay the applicable cost-share for brand medications even when
there is no equivalent generic medication or if you are unable to take a generic
medication for any reason.
Benefits and cost share for covered prescription medications may differ, depending on
where you obtain a medication (e.g., from a retail pharmacy, specialty pharmacy, in a
physician's office, through home health services).
Retail pharmacy and Mail Service prescription medication expenses typically do not
apply toward any applicable medical benefit plan out-of-pocket coinsurance maximum.
Retail and Mail Service Pharmacy Benefits for Injectable Medications
Only certain injectable medications are covered under the Retail and Mail Service
Pharmacy benefits. Other injectable medications may be covered under your medical
benefit (such as Home Health benefit or Specialty Self-Injectable Medication benefit).
See your benefit plan booklet for additional information about these benefits.
Click here for a list of injectable medications available through your retail and Mail
Service pharmacy benefits. This list is subject to change at any time without prior notice.
Deductible for Prescription Medications Obtained Under the Retail and Mail-Order Pharmacy Benefit
Some plans have a prescription deductible. With these plans, copays will not apply until
you satisfy the deductible.
Benefit Exclusions for Retail and Mail Service Pharmacy Benefits
The fact that a medication is recommended or prescribed by a physician does not make
it a benefit. Benefit plans do not cover all health care expenses and have exclusions
and limitations which may include pre-existing condition waiting periods and waivers. All
plans generally exclude coverage for medications that are experimental, investigational,
cosmetic for treatment of sexual dysfunction, or which BCBSAZ deems not medically
necessary. In addition to these general limitations and exclusions medications are
subject to certain other exclusions, including over-the-counter drugs and drugs used for
weight loss; lifestyle, fitness, or performance enhancement; and treatment of fertility
and/or infertility
For complete information on your prescription medication and medical benefits,
coverage limitations and exclusions, refer to your benefit plan booklet.
Links to Information About Retail and Mail Service Pharmacy Benefits
Level 1 & Level 2 medication lists Level 2 medication list is partial list. All medications
not assigned to level one are automatically considered as level 2 medications.
List of Retail and Mail Service injectable medications
List of Retail and Mail Service medications and vaccines subject to limitations
Vaccines available in some retail pharmacy benefits
Guidance regarding preventive medications for
PPACA
Precertification Form for Retail and Mail Service medications
List of Retail and Mail Service pharmacy in-network providers
Mail Service Pharmacy program information and form
Specialty-Self Injectable Medications and Home Health Injectable Medications
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1 You may reference web sites such as Drugs@FDA1 for general guidance on whether drugs are classified as brand or generic. Such web sites provide only general guidance, and
classifications are subject to change. Classifications found on general web sites may vary from how BCBSAZ classifies a specific drug
as brand or generic. Please contact BCBSAZ if you have questions about how we classify a specific drug.