This information applies only to Blue Cross® Blue Shield® of Arizona (BCBSAZ) customers with
the standard Three or Four Level Copay Pharmacy Benefit. It also applies to customers who have a plan requiring satisfaction of a
pharmacy deductible before application of copays. Please refer to your benefit plan booklet for information on your prescription
medication coverage. You may also contact the BCBSAZ Prescription Benefits Unit at (602) 864-4273 or (800) 232-2345, ext. 4273.
Prescription medications can be covered through several different plan benefits. Your coverage requirements and cost-share will
vary, depending on the applicable benefit and the supply source of the medication.
Depending on the specific benefit plan, the retail and mail-order pharmacy benefit has three or four cost-share (copay)
levels, which are listed on your schedule page. BCBSAZ classifies prescription medications into one of four levels that correspond
to a copay level. Your cost-share payment will depend on the specific medication dispensed by the pharmacy and the level to which
the medication is assigned when you fill your prescription. If your plan has only three cost share levels, you will pay the Level
3 copay for medications placed on Level 4.
Prescription medications may change levels at any time without prior notice. To confirm the status of a
particular medication, click here [PDF] for a list of Level 1 and
2 medications. Click here [PDF] for an alphabetical list of Level
2 medications. Click here [PDF] for a sample listing of Level 3
medications (due to the number of available medications, not all level 3 medications are listed).
Click here [PDF] for a list of Level 4 medications.
You can also call the BCBSAZ Prescription Benefits Unit at (602) 864-4273 or (800) 232-2345 ext. 4273 to confirm
the status of a particular medication.
Most generic medications are assigned to Level 1. BCBSAZ cannot guarantee that generic medications will be available when
you fill your prescription. If a generic medication is not available for your prescription, you will have to pay the copay for
whatever medication is dispensed. If you or your provider has specific questions regarding the availability of a generic medication,
please contact the dispensing pharmacy.
When you fill a covered prescription at a non-contracted pharmacy*, you will pay for your prescription in
full and submit a claim to BCBSAZ. When BCBSAZ processes your prescription claim from a non-contracted pharmacy,
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.
Please click here [PDF] to check a
pharmacy's contract status with BCBSAZ. You can also call the BCBSAZ Prescription Benefits Unit at (602) 864-4273 or
(800) 232-2345 ext. 4273.
*Blue Secure, BlueSelect, and BlueChoice customers must use network pharmacies, except for emergencies.
Filing a Prescription Medication Claim
Please use these steps to file a prescription medication claim: Mail a copy of the itemized prescription receipt(s) to:
Blue Cross Blue Shield of Arizona
P.O. Box 13466
Mail Stop A115
Phoenix, AZ 85002-3466
The receipt should include the patient's name and medication information, (medication name, the prescribing doctor's name,
quantity, NDC number, pharmacy name and cost). Be sure to include your address and BCBSAZ subscriber identification number.
Precertification
Precertification is required for certain medications covered under the retail and mail-order pharmacy benefit.
Please click here [PDF] for a list of prescription medications
that require precertification. A list of medications that require precertification is also available by calling BCBSAZ
at (602) 864-4273 or (800) 232-2345, ext. 4273. The list of specific prescription 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.
Retail and Mail-Order Prescription Medication Limitations
BCBSAZ applies limitations to certain prescription medications obtained through the retail and mail-order pharmacy benefit.
These limitations include, but are not limited to, quantity, age, refill, and gender limitations.
BCBSAZ prescription medication limitations are subject to change at any time without prior notice.
For certain prescription medications, BCBSAZ applies a per-copay quantity limitation. These medications are subject to
an additional copay each time the prescribed quantity exceeds the BCBSAZ per-copay quantity limitation. When your provider
prescribes more than the per-copay quantity limitation, you may purchase the prescribed amount. However, you will have to
pay an additional copay each time the quantity limitation is exceeded. If the prescribed quantity is above the BCBSAZ maximum
quantity for a 30-day supply (retail) or 90-day supply (mail-order), refill limitations will also apply. Prescription medication
refills are covered when approximately ¾ of the medication is used as prescribed.
Please click here [PDF] for a list of prescription medications subject
to BCBSAZ prescription medication limitations. You can also check the list of prescription medications subject to BCBSAZ
prescription medication limitations by calling the BCBSAZ Prescription Benefits Unit at (602) 864-4273 or (800) 232-2345,
ext. 4273.
Mail-Order Program
In addition to your retail pharmacy benefit, you may also have a benefit for mail-order prescription medications,
which will enable you to get up to a maximum 90-day supply. Please refer to your schedule page for copays and coinsurance
amounts, as well as some of the limitations that apply to your plan's mail-order prescription benefit. Mail order service
is subject to all exclusions and limitations of your benefit plan, including prescription medication limitations.
More Information About Your Prescription Benefits
No exceptions will be made on the cost-share amount for a particular medication, regardless of the reason or condition for
which it is prescribed.
BCBSAZ assigns medications newly approved by the FDA to Level 3 or 4 until they can be evaluated for possible inclusion on
another level.
When the price BCBSAZ pays a contracted pharmacy for a medication is less than your copay, some contracted pharmacies will
charge you the BCBSAZ price. However, most contracted pharmacies will charge you their regular retail price, if it is also less
than your copay, rather than the BCBSAZ price. You should never be charged more than your copay at a BCBSAZ contracted pharmacy.
The fact that BCBSAZ has assigned a medication to a particular level does not guarantee coverage for that medication.
Benefit plan limitations, exclusions and other factors determine if coverage is available for any specific medication.
Assignment of a medication to a particular cost-share level does not constitute a recommendation on the use of a medication. Always consult your provider to determine which medications are appropriate for you.
Benefits and cost share for covered prescription medications may differ, depending on where the medication is obtained
(e.g., from a retail pharmacy, specialty pharmacy, in a physician's office, through home health services).
Retail pharmacy and mail-order prescription medication expenses do not apply toward any applicable medical benefit plan
out-of-pocket coinsurance maximum.
Only certain injectable medications are covered under the retail and mail-order pharmacy benefit. Other injectable
medications may be covered under your Home Health benefit or your Specialty Self-Injectable Medication benefit, subject to
BCBSAZ medical necessity guidelines. See your benefit plan booklet for additional information about these benefits.
Please click here [PDF] for a list of injectable
medications available through the retail and mail-order pharmacy benefit. Injectable medication lists are also available
by calling BCBSAZ at (602) 864-4273 or (800) 232-2345, ext. 4273.
Deductible for Prescription Medications Obtained Under the Retail and Mail-Order Pharmacy Benefit
Certain plans have a prescription deductible for Level 2, 3, and 4 prescription medications. See your schedule page for
this deductible amount. Copays will not apply to any medications on these levels until you satisfy the deductible. The
amount counted toward satisfaction of this deductible is the BCBSAZ allowed amount assigned to each eligible medication, and
not the retail price. After meeting any required prescription deductible, you will pay the applicable copay for medications
on Levels 2, 3, or 4.
Amounts applied to your prescription deductible do not count toward any other plan deductible or out-of-pocket coinsurance
maximum. The prescription deductible is per member, per calendar year.
Retail and Mail-Order Pharmacy Benefit Limitations and Exclusions
The fact that a medication is recommended or prescribed by a physician does not make it a benefit. Prescription
medication benefits are subject to all the limitations and exclusions stated within your benefit plan, in addition to the
following specific limitations and exclusions:
- Administration of a covered medication
- Certain categories of injectable medications
- Compounded medications obtained from a mail-order pharmacy
- Immunizing agents and biological serums
- Medications, devices, equipment and supplies lawfully obtainable without a prescription
- Medication delivery implants
- Medications designed for weight gain or loss, including but not limited to, Xenical® and Meridia®, regardless of the condition for which it is prescribed
- Medications dispensed to a member who is an inpatient in any facility
- Medications for athletic performance
- Medications for lifestyle enhancement
- Medications for sexual dysfunction
- Medications labeled "Caution - Limited by Federal Law to Investigational Use" or words to that effect and any experimental medications as determined by BCBSAZ, except as stated in your plan
- Medications obtained from an out-of-network mail-order pharmacy
- Medications packaged with one other or multiple other prescription products
- Medications packaged with over-the-counter medications, supplies, medical foods, vitamins or other excluded products
- Medications to improve or achieve fertility or treat infertility
- Medications used for any cosmetic purpose
- Medications used to treat a condition not covered under your plan
- Medications with primary therapeutic ingredients that are sold over the counter in any form, strength, packaging or name
- Prescription medications dispensed in unit-dose packaging, unless that is the only form in which the medication is available
- Prescription refills for medications that are lost, stolen, spilled, spoiled or damaged
- Smoking cessation medications and devices of any kind
- Specialty self-injectable medications
For complete information on your prescription medication and medical benefits, coverage limitations and exclusions, refer to your benefit plan booklet. All other exclusions and limitations of your benefit plan will apply.