This process encourages medically appropriate and cost-effective use of certain drugs. You can easily find these drugs on your formulary by looking for the PAR symbol next to their names.
To help prevent possible delays in filling prescriptions that require prior authorization, you or your doctor should request prior authorization before your prescriptions are filled. Your benefits will not cover prescription drugs that require prior authorization until the authorization is secured.
Your in-network doctor will request prior authorization for you. You can also start a prior authorization request by calling the Member Services number on your member ID card or by logging in to your secure account. You will need:
- Your name (as it appears on your member ID card)
- Your member number
- Your date of birth
- Name of the drug
- Name of the doctor who prescribed the drug
- Prescribing doctor’s phone number
- Prescribing doctor’s fax number (if available)
If your authorization is not approved, you can still get your prescription; however, you will be responsible for the entire cost of the drug. You may appeal the decision or you may ask your doctor to prescribe another drug that is covered by your benefits. Note that if your prescribing doctor is not in Capital BlueCross’ network, you are responsible for requesting prior authorization.
Enhanced Prior Authorization5 (Step Therapy)
Your plan includes a process called enhanced prior authorization for certain prescription drugs, which means you may be asked to try a different drug first. Your doctor or pharmacist can call Capital BlueCross at the phone number listed on your member ID card to start enhanced prior authorization. You can also start the process by calling the Member Services number on your member ID card or through your secure account.
Drug Quantity Management Program
Your plan also includes quantity limits for certain prescription drugs to support safety. Prescription drugs that require quantity level limits will have a QLL symbol next to their name on your formulary. If your prescription is written for more than the allowed quantity, your pharmacy will only fill up to the allowed amount. Your doctor can request an exception to quantity limits by calling the number on your Capital BlueCross member ID card.
Generic Substitution Program
Your benefits may include a mandatory or restrictive generic substitution program to help you save money and control drug costs. Under the mandatory program, your pharmacy may replace a brand-name drug with a generic one. If you request the brand-name one, you will be charged the brand-name cost share plus the cost difference between the generic and brand-name medication.
Under the restrictive program, your doctor can write Brand Medically Necessary on your prescription. In this case, you will only be charged the brand-name cost share. However, if you request a brand-name drug when a generic is available, you will be charged the brand-name cost share plus the cost difference between the generic and brand-name medication. Check your plan highlight sheet or Certificate of Coverage to see if either program applies to your plan.
Specialty Drugs (self-administered)
AllianceRx Walgreens Prime serves as your plan’s specialty drug pharmacy. If you need a specialty drug to manage your unique health condition, a patient care coordinator from AllianceRx Walgreens Prime will work with a team of pharmacists, nurses, your doctor, and Capital BlueCross to give you personalized care that helps best manage your needs. Your services include:
- Help getting prior authorization and refills
- The convenience of having your drugs delivered directly to your home at no additional cost
- Free supplies, such as needles, syringes, and disposal containers
- Training and educational resources to help ensure you know how to take your medication
- Care management programs that can help you get the best results from our prescribed drug therapy
Your Certificate of Coverage includes specific terms, conditions, exclusions, and limitations about your specialty drug benefits.
For more information about specialty drugs, call AllianceRx Walgreens Prime at 800.533.7606.
As a Capital BlueCross member, you have access to thousands of retail pharmacies across the country, including many well-known chains (such as CVS, Rite Aid, Target, and Wal-Mart), grocery stores, and independent pharmacies. To help ensure you pay the lowest amount for your prescription drugs, use a pharmacy in your plan’s network. You can find in-network pharmacies by logging in to your secure account calling the Member Services number on your member ID card.
If your plan includes this program, you must get your maintenance drugs in 90-day supplies. Remember to ask your doctor to write a 90-day prescription. You can fill your 90-day prescriptions for maintenance drugs through home delivery or by picking them up at pharmacies that are part of the Extended Supply Network.
Some plans allow an initial 30-day fill and a 30-day refill for maintenance drugs before 90DayMyWay requires members to get 90-day fills. Check your certificate of coverage for details. Drug quantity level limits apply to all applicable generic equivalents of the brand-name products. Applicable home delivery quantity levels are two to three times the retail quantity level limits, depending on the prescription drug benefit design chosen by the member or employer group.
Extended Supply Network
This network includes pharmacies that are allowed to dispense prescriptions drugs in amounts up to 90 days. Most of the popular retail chain and grocery store pharmacies are part of the Extended Supply Network. You can find which pharmacies are part of the Extended Supply Network by logging in to your secure member account or calling the Member Services number on your member ID card.
Log in to your secure account to manage your prescription drug benefits. See which drugs are covered by your plan (your formulary), find pharmacies, and learn more about your plan’s prescription drug programs in this one-stop shop. Also, your Member Services team is available 24 hours a day, seven days a week to answer your pharmacy benefit questions. You can call them at the number on your member ID card.