Please note: The information on this page does not apply to our Affordable Care Act (ACA) plans. For ACA members, please call 855-811-2218 for more information.

*Any medication names listed below may be the registered or unregistered trademarks of independent third-party pharmaceutical companies. These trademarks are included for informational purposes only and are not intended to imply or suggest any third-party affiliation.

PreCheck MyScript

PreCheck MyScript^® is a real-time benefits check tool embedded within the electronic medical record (EMR) workflow. It displays lower-cost alternatives for prescriptions, which medications require prior authorizations (PAs), and more.

• Average savings for physicians and office staff for each PA that is avoided is $41.
• Average time savings for physicians and office staff for each PA that is avoided is 50 minutes.

PreCheck MyScript seamlessly integrates with many common EMR platforms, with additional integrations ongoing.

Benefits of PreCheck MyScript:

• $225 average member savings per prescription switch
• Less faxing or calling for prior authorizations.
• Lower costs improve patient medication adherence and clinical outcomes.
• More time with patients and less administrative tasks.

Formularies and Drug Search

Different formularies may cover different drugs, place drugs at different copay tiers, or have different management programs. A member's specific health plan determines which drug lists apply to them. Members who are not sure which drug lists apply to their plans can log into My Health Toolkit^® for personal information.

• Lowest Net Cost Formulary (Drug Search 2024)
• Premium Formulary (Drug Search 2024)
• Select Formulary (Drug Search 2024)

Nonformulary and Excluded Drugs

From time to time, our pharmacy committee may decide to no longer cover some drugs when other safe, effective, less costly alternatives are available. Those drugs are then moved to nonformulary status. Additionally, some plans may exclude coverage for certain categories of drugs, such as those for weight loss, fertility, or sexual dysfunction. Review the excluded drug list for more information.

• Optional Drug List - The drugs on this list are specialty products that are not covered for most members unless specifically elected by their employer group.

Prior Authorization for Nonspecialty Drugs

We require prior approval for drugs included in our prior authorization program for most members.

CoverMyMeds

Our pharmacy benefit manager has partnered with CoverMyMeds to offer free electronic prior authorization (ePA) services to all providers and their staff. ePA helps prescribers and pharmacies quickly find, complete and submit prior authorization (PA) requests.

You can use CoverMyMeds to:

• Submit the request electronically.
• Quickly find the correct PA request form for your patient’s plan.
• Receive real-time plan specific clinical guideline questions (where applicable).
• Complete PA requests started by pharmacies.
• Easily manage follow-ups for all your requests and patients.
• Check status of ePA requests submitted.

To get started all you need to do is register for a free account or log into your existing CoverMyMeds account.

Create an account by:

• Clicking on the “Get Started” red button.
• Filling out required basic account information:
  • Full name
  • Email address
  • Office type
  • Username and password

View the demonstration for more details.

Our pharmacy benefit manager also accepts prior authorizations via phone and fax. To request prior authorization for non-specialty drugs, call the Prior Authorization department at 855-811-2218 (Commercial) or 855-540-5951 (Part D), or print the required prior authorization form and fax it to 844-403-1029 (Commercial) or 844-403-1028 (Part D).

Quantity Management Program

We limit the amount we cover for medications included in the quantity management program for many members. We cover higher quantities for some medications when medical necessity is documented.

Step Therapy Program

We require a generic or over-the-counter alternative trial before we cover medications included in the step therapy program for most members. We waive this requirement when medical necessity is documented.

Specialty Drugs

Specialty drugs can be costly for our members, and not all plans cover them the same way. That’s why it’s important to review whether the use of these medications meets coverage criteria before a specialty drug is provided.

Specialty Drugs Covered Under the Pharmacy Benefit

Review the available information on specialty drug coverage under the pharmacy benefit.

Specialty Drugs Covered Under the Medical Benefit

To find out which medical specialty drugs require prior authorization under the Specialty Medical Benefit Management (SMBM) program, view the Medical Drug List.

Note: Some infused specialty medications commonly administered in the hospital setting can be safely provided at home, in a physician’s office, or in an infusion suite. Drugs with a site-of-care requirement may only be approved in certain sites of care or if the patient is under 18 years of age.

Certain self-administered drugs aren’t covered under the medical benefit. The drugs on the Self-Administered Drug List must be billed under the pharmacy benefit. There are some exceptions. Hematologists, oncologists, nephrologists and rheumatologists may continue to bill for these drugs under the medical benefit. Additionally, some member benefit plans may be exempt. 

We make changes to all our drug lists from time to time. Updates usually occur quarterly but can happen at any time. It’s always a good idea to review the latest version before providing a specialty drug to one of your patients who has coverage through BlueCross.

You can request prior authorization for these specialty drugs by using MBMNow through My Insurance Manager^SM (MIM). 

1. Log into MIM.
2. Select the “Patient Care” tab.
3. Under “Health,” look for “Pre-Certification/Referral.” 
4. When you indicate your request is for a specialty drug, the system will route you to MBMNow.
5. Initiate your prior authorization request.

Generic Drugs

Some of our members have a Dispense as Written (DAW) generic program as part of their prescription drug benefits. 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 you feel that the generic version is not appropriate for a particular member, please complete this Generic Program Exception Form to request an exception detailing why this member must have the brand-name drug over the generic version. This exception process is only applicable to members whose benefits are subject to the rules under the ACA/essential health benefits for prescription drug coverage.