Effective October 1, 2006 for Under-65 Individual Products
Effective January 1, 2007 for new groups and upon each group's renewal
This information applies only to Blue Cross Blue Shield of Arizona (BCBSAZ) customers
with the standard Tiered Copay Pharmacy Benefit. Please refer to your contract or
benefit plan booklet for 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 obtained at a pharmacy, administered in a physician's office or through
home health services or acquired under other coverage provisions within your benefit
plan or contract.
The retail and mail order pharmacy benefit has four cost-sharing levels. Prescription
medications are classified in one of four levels of cost-sharing for which you are
responsible. The amount you pay will depend on the specific medication dispensed
by the pharmacy. The pharmacy will charge you a Level 1, 2, 3 or 4 copay. Your copays
for each level are listed on your schedule page. The level of benefit you receive
is based on the level the medication is on at the time you fill your prescription.
Prescription medications may change levels at any time without prior notice.
To confirm the status of a particular medication, click here for a list of Level
1 and 2 medications. Click here for an alphabetical list of Level 2 medications.
Click here for a sample listing of Level 3 medications. Click here for a list of
Level 4 medications. You can also call the BCBSAZ Prescription Customer Service Unit
at (602) 864-4273 or (800) 232-2345 ext. 4273 to confirm the status of a particular
medication.
The generic medications listed in this Guide represent only a sample of generic
medications that may be available; BCBSAZ cannot guarantee that generic medications
listed in this Guide will be available at the time you get your prescription filled.
Further, listing in this Guide does not imply that you will receive a brand-name
medication at the Level 1 copay if a generic medication is not available for your
prescription. If you or your provider has specific questions regarding the availability
of a generic medication, please contact the dispensing pharmacy.
If your plan has a 3-tier prescription medication benefit, you will pay the Level
3 copay for medications listed under Level 4; if your plan has a 4-tier benefit,
you will pay the Level 4 copay.
When you fill a covered prescription at a noncontracted pharmacy*, you will pay
for your prescription in full and submit a receipt with your subscriber identification
number to BCBSAZ. When BCBSAZ processes your prescription claim from a noncontracted
pharmacy, you will be responsible for any applicable deductible, coinsurance or
copay amount in addition to the difference between the price charged by the pharmacy
and the BCBSAZ allowed amount. Please Click here for a list of independent and chain
drug stores which are contracted pharmacies.
*BlueSelect and BlueChoice customers must utilize 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 your 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 your retail and
mail order pharmacy benefit. Click here for a list of prescription medications that
require precertification. A list of medications that require precertification is
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, 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. The claim for such medication will not be denied for lack of
precertification, but all other exclusions and limitations of your contract or benefit
plan will still apply.
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 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 prescription medications will be subject to an additional copay each time
the amount prescribed exceeds the BCBSAZ per-copay quantity limitation. When your
provider prescribes more than the per-copay quantity limitation, you may obtain
the prescribed amount. However, you will have to pay an additional copay each time
the quantity limitation is exceeded, and if it 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.
Click here 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 Customer Service Unit at (602) 864-4273 or (800) 232-2345, ext.
4273.
Mail Order Program
In addition to filling your prescription at a retail pharmacy, you may also have
a prescription medication mail order service benefit.This service is available for
maintenance medications (those you take on an on-going basis). Up to a 90-day supply
of maintenance medications (the same medication and medication strength) may be
obtained. Please refer to your schedule page for copays and/or coinsurance amounts,
as well as any limitations that apply to your plan's mail-order prescription benefit.
BCBSAZ prescription medication limitations apply to medications obtained through
the mail order program. See "Retail and Mail Order Prescription Medication Limitations”
above. All other exclusions and limitations of your contract or benefit plan will
apply to mail-order service.
Important Information
No exceptions will be made on the cost-sharing amount for a particular medication,
regardless of the reason it is prescribed.
Medications newly approved by the FDA are assigned 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 usual and customary 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 and/or included
it in this Guide does not guarantee coverage for that medication. Benefit plan or
contract limitations, exclusions and other factors determine if coverage is available.
In addition, the assignment of a medication to any particular 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 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).
Prescription medication expenses do not apply toward any applicable medical benefit
plan out-of-pocket coinsurance maximum.
Only certain categories of injectable medications are available from retail and
mail order pharmacies. 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 contract or benefit plan booklet for
additional information about these benefits. Click here for a list of injectable
medications available through the retail and mail order pharmacy benefit. Other
injectable medication lists are also available by calling BCBSAZ at (602) 864-4273
or (800) 232-2345, ext. 4273.
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 contract or benefit plan, in addition to the following
specific limitations and exclusions:
- 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 booklet.
- 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 does not include medications used for the treatment of cancer.
- Medications for sexual dysfunction, except as stated in your contract or benefit
plan booklet
- Medications to improve or achieve fertility or treat infertility, except as stated
in your contract or benefit plan booklet
- 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, except as stated in your contract
or benefit plan booklet.
- 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 you 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
- Any medication used to treat a condition not covered under your contract or benefit
plan
For complete information on 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 benefit plan or contract will apply.