Blue Preferred Basic Plans

Effective October 1, 2007 for Under-65 Individual BluePreferred Basic Products

Effective November 1, 2007 for Group BlueSolutions Benefit Plans

Effective January 1, 2008 for Group BluePreferred Basic Benefit Plans

This information applies only to Blue Cross® Blue Shield® of Arizona (BCBSAZ) customers enrolled in a BluePreferred Basic or BlueSolutions plan. Please refer to your contract or benefit plan booklet for complete information on your prescription medication coverage. You may also contact the BCBSAZ Prescription Customer Service Unit at (602) 864-4273 or (800) 232-2345, ext 4273 for details of your coverage.

Benefits for covered prescription medications may differ depending on whether the medication is purchased at a pharmacy, administered in a physician's office, delivered through home health services, or acquired under other coverage provisions of your benefit plan.

Retail Pharmacy Benefit

You may obtain up to a 30-day supply of prescription medication through a retail pharmacy. The retail pharmacy benefit has two cost-sharing levels for prescriptions obtained from a BCBSAZ contracted pharmacy. The amount you pay will depend on the specific medication dispensed by the pharmacy. For covered generic prescription medications, the contracted pharmacy will charge you a copay as shown on your schedule page. For brand name prescription medications, the pharmacy will charge you the lesser of the BCBSAZ price (the price for which BCBSAZ has contracted with the pharmacy) or the maximum amount per prescription shown on your schedule page. Please check your schedule page for cost-sharing amounts.

Whether a medication is considered generic or brand name is based on the level of the medication at the time you fill your prescription. Medications may change cost-sharing levels without notice. You or your provider may contact BCBSAZ to check on the status of a medication.

When you fill a covered prescription at a noncontracted pharmacy, you will pay for your prescription in full and submit a prescription medication claim to BCBSAZ. When BCBSAZ processes your prescription medication claim from a noncontracted pharmacy, you will be responsible for any applicable deductible, coinsurance or copay amount, plus the difference between the price charged by the pharmacy and the BCBSAZ allowed amount.

Filing a Prescription Medication Claim

To file a prescription medication claim, simply mail a copy of the itemized prescription receipt(s) to: BCBSAZ Prescription Customer Service Unit, Mail Stop A115, P.O. Box 13466, Phoenix, AZ 85002-3466. The receipt should include your name and prescription medication information (medication name, the prescribing doctor's name, quantity, National Drug Code number, pharmacy name and cost). Be sure to include your address and BCBSAZ subscriber identification number.

Mail Order Pharmacy Benefit

Up to a 90-day supply of maintenance medications (the same medication and medication strength) may be obtained through the prescription medication mail order benefit. Maintenance medications are medications you take consistently. A mail order benefit is only available through the contracted mail order provider and is not covered through a noncontracted provider. Payment must be made with a debit or credit card. Please refer to your schedule page for cost-sharing amounts.

Injectable Medications

Only certain categories of injectable medications are covered through the retail and mail order pharmacy benefit. Other injectable medications may be covered through the Specialty Injectable Medication benefit or the Home Health benefit, subject to BCBSAZ medical necessity guidelines. Precertification is required for both the Specialty Injectable benefit and the Home Health benefit, and all other limitations and exclusions of your contract or benefit plan will apply. Click here for the list of injectable drugs covered through the Pharmacy Benefit or you may call the BCBSAZ Prescription Customer Service Unit at (602) 864-4273 or (800) 232-2345, ext. 4273 if you have questions regarding these injectable medications.

Cost Sharing

• Your pharmacy copays and coinsurance payments do not apply toward the annual deductible under your benefit plan.
• Pharmacy copay or coinsurance amounts do not apply toward any applicable out-of-pocket coinsurance maximum under your benefit plan.
• When the price BCBSAZ pays a contracted pharmacy for a medication is less than your copay, some pharmacies will charge you the BCBSAZ price. However, most pharmacies will charge you their retail price (if also less than the copay), rather than the BCBSAZ price. You should never be required to pay more than your copay for a generic medication at a contracted pharmacy.
• No exceptions will be made concerning the copay or coinsurance that will apply, regardless of the medical reasons that might necessitate use of a particular prescription medication. This means if you are taking a medication, you will pay the applicable cost-sharing amount for that medication even if there is no equivalent medication at a lower cost, or you are unable to take a lower cost, equivalent medication for any reason.

Retail and Mail Order Pharmacy Benefit 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 and gender limitations. BCBSAZ prescription medication limitations are subject to change at any time without prior notice.

Prescription medications that have quantity limitations are subject to additional cost sharing each time the amount prescribed exceeds the BCBSAZ per-prescription quantity limitation. When your provider prescribes more than the quantity limitation, you may obtain the prescribed amount. However, you will have to pay additional cost sharing each time the quantity limitation is exceeded. If it is above the BCBSAZ maximum quantity, refill limitations will also apply. Prescription medication refills are covered when approximately ¾ of the medication is used as prescribed.

Click here for the list of prescription medications subject to BCBSAZ prescription medication limitations, or you may call the BCBSAZ Prescription Customer Service Unit at (602) 864-4273 or (800) 232-2345, ext. 4273.

Precertification

Precertification is required for certain medications covered under the retail and mail order pharmacy benefit. For a list of medications that require precertification and the process for obtaining precertification, click here, or you may call the BCBSAZ Prescription Customer Service Unit at (602) 864-4273 or (800) 232-2345, ext. 4273. Otherwise covered eligible medications will not be covered if precertification is not obtained when required. The list of specific 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, you may be required to pay for the medication at the time it is dispensed to you. In those cases, you may file a claim to BCBSAZ for reimbursement. BCBSAZ will not deny your claim for lack of precertification, but all other limitations and exclusions of your contract or benefit plan will still apply.

Retail and Mail Order Pharmacy Benefit 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 in your contract or benefit plan. The following are specifically excluded from coverage:

• Any medication, device, equipment and/or supply (except for diabetic supplies and inhaler spacers) that is lawfully obtainable without a prescription, i.e., over-the-counter items.
• Any vitamins, minerals, dietary and nutritional supplements, special foods or diets, except as stated in your contract or benefit plan.
• Medications for off-label, unlabeled or orphan medications (orphan medications are used for diagnosis, treatment or prevention of a rare disease or condition) unless otherwise specified by BCBSAZ medical or prescription medication coverage guidelines. This exclusion does not include medications used for the treatment of cancer.
• Medications for sexual dysfunction.
• Medications to improve or achieve fertility or treat infertility.
• Performance, athletic performance or lifestyle enhancement medications or supplies.
• Smoking cessation medications or devices, regardless of whether a prescription is required.
• Immunizing agents or biological serums sold as separate items.
• Medication delivery implants.
• Administration of a covered medication.
• Any medication labeled "Caution - Limited by Federal Law to Investigational Use," or words to that effect, and/or any experimental medication as determined by BCBSAZ, even though you would be charged for this medication.
• Any prescription medication dispensed in unit-dose packaging, unless that is the only form in which the medication is available.
• Any medication 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 subscriber while an inpatient in any facility. To the extent facility coverage is available, medications are included in the reimbursement to the facility, and are not separately covered under the Retail and Mail Order Pharmacy Benefit. If the facility services are not covered, there is no coverage for medications dispensed at the facility.
• Prescriptions or refills for medications that are lost, stolen, spilled, spoiled or damaged.
• Any medication used for any cosmetic purpose, including but not limited to, hair growth or hair removal.
• Specialty self-injectable medications (such medications may be covered under other benefits, such as specialty injectable or home health).
• Any medication used to treat a condition not covered under this contract or benefit plan.

The following are excluded from coverage under the mail order pharmacy benefit:

• Compounded medications (may be covered under retail pharmacy benefit).
• Medications obtained from a mail order pharmacy not contracted with BCBSAZ to provide mail order prescription benefits.

For more information about your prescription medication and medical benefits, coverage limitations and exclusions, refer to your contract or benefit plan booklet. All other exclusions and limitations of your contract or benefit plan booklet will also apply.