Drug Lists and Forms
If you have: |
Group Coverage From Your Employer or PersonalBlue PPO |
Individual Coverage From Capital BlueCross or HealthCare.gov |
|---|---|---|
Drug Formulary |
2019 Formulary (Open/Closed) | 2019 Formulary (Selectively Closed) |
Formulary Updates |
Open/Closed Formulary
|
Selectively Closed Formulary
|
Prior Authorization, Enhanced Prior Authorization (Step Therapy), Quantity Level Limits, and Specialty Medication Lists |
2019 Pharmacy Benefit Information (for open/closed formulary) | 2019 Pharmacy Benefit Information (for selectively closed formulary) |
PPACA Preventive ServicesSome preventive medications may be covered at no cost to you when filled at a participating pharmacy with a valid prescription. |
PPACA Preventive Medications (includes vaccine coverage) |
PPACA Preventive Medications (includes vaccine coverage) |
QHDHP Preventive Drugs(In 2019, this option is available only to large groups of 100+ employees.) If elected by your employer, some preventive and maintenance medications will have the deductible waived, and you will be charged only a copay. |
QHDHP Preventive Medications |
Not applicable |
Blood Glucose Meter Program |
Blood Glucose Meters | |
General Forms |
Prescription Claim Form | |
Mail Orders |
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On behalf of Capital BlueCross, CVS/caremark™ assists in the administration of our prescription drug program. CVS/caremark is an independent pharmacy benefit manager.
On behalf of Capital BlueCross, AllianceRx Walgreens Prime, an independent company by Walgreens Specialty Pharmacy Holdings, LLC, assists in dispensing specialty medications for our members.