Pharmacy: Frequently Asked Questions

A generic drug is the same as a brand-name drug in dosage, safety, strength, how it is taken, quality, performance, and intended use.

Before approving a generic drug product, the Food and Drug Administration (FDA) requires many rigorous tests and procedures to ensure that the generic drug can be substituted for the brand-name drug.

A brand-name drug is a drug marketed under a proprietary, trademark-protected name.

A preferred drug is a drug that may offer a clinical or cost advantage over other drugs in the same therapeutic category.

A non-preferred drug is a drug that typically has higher member cost-sharing because it does not offer a clinical or cost advantage over preferred drugs.

A specialty drug is a drug used to treat complex, chronic and/or life threatening conditions.

Specialty drugs often require special handling (like refrigeration during shipping) and administration (such as injection or infusion).

You can view specialty drugs that may apply to the plan at AlabamaBlue.com/SelfAdministeredSpecialtyDrugList.

See your benefit book for details regarding your plan’s specific specialty drug coverage.

A non-essential drug is a drug that is excluded from your plan’s prescription drug benefit for a number of reasons. Examples of drugs deemed non-essential are non-FDA approved drugs, repackaged drugs, bulk powders, and cosmetic agents.

A provider-administered drug is a drug that is administered or directly supervised by a healthcare provider on an outpatient basis in a hospital, other medical facility or physician’s office.

Provider-administered drugs do not include drugs that are typically available by prescription order or refill at a pharmacy.

Provider-administered drug coverage is subject to Drug Coverage Guidelines. You can view provider-administered drugs that may apply to the plan at AlabamaBlue.com/ProviderAdministeredPrecertificationDrugList.

See your benefit book for details regarding your plan’s specific provider-administered drug coverage.

Drugs are classified in categories known as “drug tiers”.

The copay or coinsurance for each drug tier is based on:

• Drug usage
• Cost of the drug
• Availability of over-the-counter options
• Clinical effectiveness

To determine the drug tier a specific drug is classified in by your benefit plan, log into myBlueCross at AlabamaBlue.com. Then search for the drug by clicking the “Find Drug Pricing” link located in the Manage My Prescriptions section.

Drug tier classifications are updated periodically.

A drug list or “formulary” is a list of therapeutically appropriate drugs that your benefit plan covers.

Covered drugs on a drug list are selected based on the recommendations of a Pharmacy and Therapeutics (P&T) Committee.

Drugs are deemed appropriate for coverage by evaluating numerous factors such as:

• Safety
• Effectiveness
• Cost

Always refer to your benefit booklet for the specific drug list that applies to your plan.

If your benefit plan has mandatory generics, it means a brand-name drug will be non-covered when it has a generic equivalent available.

An alternative drug list is a publication that lists many of the non-covered drugs on your benefit plan’s drug list along with their covered preferred alternative drugs.

A maintenance drug list is a list of drugs that are generally used to treat chronic or long-term conditions.

These conditions, such as high blood pressure, heart disease and diabetes, usually require regular, daily use of maintenance drugs.

As part of the Affordable Care Act (ACA), certain employers or plans can elect to provide coverage at no cost to members for preventive drugs listed on the ACA preventive drug list.

Your benefit plan may require that a generic preventive drug be used.

A Prior Authorization (PA) or Precertification means that your plan must give prior approval before it will cover certain drugs.

If you have been prescribed a drug that requires a PA, your doctor must first send a request for authorization to Blue Cross and Blue Shield of Alabama.

Once approved, you will be able to fill the prescription for your medication.

Your copay or coinsurance will vary based on your specific benefit plan.

Many benefit plans offer a lower copay for lower drug tiers and require a higher copay for higher drug tiers.

Your pharmacy benefits are listed in your benefit booklet under Prescription Drug Benefits.

Members can look up how much they will pay at the pharmacy for a specific drug by logging into myBlueCross at AlabamaBlue.com. Once logged in, select “Find Drug Pricing” located under Manage My Prescriptions.

A drug exclusion or non-covered drug is a drug that is not covered on your benefit plan’s drug list.

If a drug is not covered, it could be for reasons such as:

• The availability of lower cost generics or alternatives
• Safety concerns
• Lack of FDA approval
• The availability of over-the-counter alternatives

When a drug is excluded or non-covered, benefits are not provided for that drug and if you continue taking it, you will pay the full cost of the drug.

A Retail pharmacy is a licensed pharmacy that generally dispenses up to a 30-day supply of maintenance and non-maintenance drugs.

An Extended Supply Network (ESN) pharmacy is a licensed pharmacy that generally dispenses up to a 90-day supply of maintenance drugs.

A Specialty pharmacy is a licensed pharmacy that generally dispenses up to a 30-day supply of drugs used to treat complex chronic and/or life threatening conditions.

A Home Delivery Network is a mail order network that includes a licensed pharmacy that generally dispenses up to a 90-day supply of maintenance drugs and delivers them to your home. AllianceRX Walgreens Prime is the in-network pharmacy for the Home Delivery Network.

See your benefit book for your plan’s pharmacy network.

To search for a network pharmacy in your plan’s pharmacy network:

• Log in at myBlueCross at AlabamaBlue.com
• Click on Find a Doctor, then select “Find a Pharmacy”
• Click “Accept” for Prime Therapeutics’ third-party disclaimer
• Your pharmacy network name will be displayed under the search bar
• To find network pharmacies you can enter a search location by using the zip code or city and state for the area you would like to search
• Click the “Search” button to find a pharmacy in your network

Your specialty pharmacy depends on the specialty network that applies to your specific benefit plan.

Benefit plans can have the Pharmacy Select Network, the Pharmacy Select Exclusive Network, or the Open Specialty Network.

See your benefit book for your plan’s specialty pharmacy network.

Prescription drug coverage is subject to Drug Coverage Guidelines developed and modified over time.

These guidelines are based upon daily or monthly limits as recommended by the FDA, the manufacturer of the drug, and/or peer-reviewed medical literature.

Even though your physician writes a prescription for a drug, that drug may not be covered under the plan or clinical edit(s) may apply (i.e. prior authorization, step therapy, quantity limits) in accordance with the guidelines.

A drug may not be covered under the plan because, for example, there are safety and/or effectiveness concerns or there are over-the-counter equivalent drugs available.

The guidelines in some instances also require you to obtain prior authorization as to the medical necessity of the drug.

Go to AlabamaBlue.com/DrugList to find the Drug Coverage Guidelines. There you can search by drug name to find the drug coverage guidelines for medications.

Step Therapy ensures that clinically effective medications for a particular condition are used before “stepping up” to another medication, for cost or quality reasons.

If these “first step” medications prove to be inappropriate for clinical reasons, then the original medication prescribed by your doctor may be approved by your plan.

Go to AlabamaBlue.com/DrugList to find the Drug Coverage Guidelines. There you can search by drug name to find the step therapy guidelines for specific drugs.

Quantity Limits allow a pharmacy to give you only enough medicine to cover a certain period of time.

Quantity Limits are usually set for more expensive drugs or for drugs that may be overused or abused.

Go to AlabamaBlue.com/DrugList to find the Drug Coverage Guidelines. There you can search by drug name to find the quantity limit guidelines for specific drugs.

If you have questions about your drug coverage, call the number on the back of your Blue Cross member identification card or go to AlabamaBlue.com/ContactUs.