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Prescription Drug Information

Prescription drugs are an important part of your health care coverage. If you have prescription drug coverage through Blue Cross and Blue Shield of Texas (BCBSTX), we want to help you better understand your prescription drug coverage and options, including convenient services and any limitations. Here you'll find helpful information and forms you need.

This is only a brief description of some of the prescription drug benefits. Not all benefits are offered by all health plans. For more complete details, including benefits, limitations and exclusions, please refer to your benefit materials.

Prescription Drug Lists for Metallic Individual Plans

A drug list is a list of preferred drugs available to BCBSTX members. How much you pay out-of-pocket for prescription drugs is determined by whether your medication is on the list. These prescription drug lists have different levels of coverage, which are called "tiers." Generally, how much you pay out of pocket for a prescription drug will be less if you choose a drug that is a lower tier.

The drug lists below are used with your health plan if all of these apply to you:

  • You enrolled in a plan on your own (instead of through your employer),
  • Your coverage began on or after January 1, 2014, and
  • Your plan is a "metallic" health plan, which can include a Platinum, Gold, Silver, Bronze, Multi-State or Catastrophic plan.

Your prescription drug benefits through BCBSTX may be based on one of two different drug lists:

  • A Standard Drug List is a list of preferred drugs which are considered to be safe and cost-effective.
  • A Generics Plus Drug List is a smaller version of the Standard Drug List. It covers drugs for the major drug classes, but includes mostly generic drugs and fewer brand-name drugs.

These drugs lists are effective January 1, 2014:

Want to know which Drug List your Texas Health Insurance Marketplace plan uses?

Prescription Drug Lists for Grandfathered Individual Plans

Note: The 2014 drug lists may not apply for all members. Please call customer service to confirm your correct drug list.

A drug list is a list of preferred drugs available to BCBSTX members. How much you pay out-of-pocket for prescription drugs is determined by whether your medication is on the list. Within a Drug List, generally the lower the tier, the lower the cost of the drug.

The drug lists below are used with your health plan if all of these apply to you:

  • You enrolled in a plan on your own (instead of through your employer),
  • Your current BCBSTX policy was effective before January 1, 2014, and
  • Your plan is not a "metallic" health plan.

Your prescription drug benefits through BCBSTX may be based on one of two different drug lists:

  • A Standard Drug List is a list of preferred drugs which are considered to be safe and cost-effective.
  • A Generics Plus Drug List is a smaller version of the Standard Drug List. It covers drugs for the major drug classes, but includes mostly generic drugs and fewer brand-name drugs.

These updated drugs lists apply starting January 1, 2014:

Prescription Drug Lists for Employer-offered Plans: Large Group (51 or more employees)

Note: The 2014 drug lists may not apply for all members. Please call customer service to confirm your correct drug list.

A Drug List is a list of preferred drugs that are available to BCBSTX members. These drugs are considered to be safe and cost-effective. How much you pay out-of-pocket for prescription drugs is determined by whether your medication is on the list. Within a Drug List, generally the lower the tier, the lower the cost of the drug.

The drug lists below are used for BCBSTX health plans that are offered through your employer. If your company has 51 or more employees, your prescription drug benefits through BCBSTX may be based on the Preferred Drug List or the Generics Plus Drug List. The Generics Plus Drug List is a smaller version of the Standard Drug List. It includes mostly generic drugs and fewer brand-name drugs. The Generics Plus Drug List covers drugs for all the major drug classes.

These Drug Lists are effective starting January 1, 2014:

Prescription Drug Lists for Employer-offered Metallic Plans: Small Group (1–50 employees)

A Drug List is a list of preferred drugs that are available to BCBSTX members. These drugs are considered to be safe and cost-effective. How much you pay out-of-pocket for prescription drugs is determined by whether your medication is on the list. These prescription drug lists have different levels of coverage, which are called "tiers." Generally, how much you pay out of pocket for a prescription drug will be less if you choose a drug that is a lower tier.

The Drug Lists below are used with BCBSTX "metallic" health plans that are offered through your employer. These can include Platinum, Gold, Silver, or Bronze plans.

If your company has 1-50 employees, your prescription drug benefits through BCBSTX may be based on either a Standard Drug List or a Generics Plus Drug List. The Generics Plus Drug List is a smaller version of the Standard Drug List. It includes mostly generic drugs and fewer brand-name drugs. The Generics Plus Drug List covers drugs for the major drug classes.

These Drugs Lists are effective January 1, 2014:

Want to know which Drug List your Texas Health Insurance Marketplace plan uses?

Prescription Drug Lists for Employer-offered Non-Metallic Plans: Small Group (1–50 employees)

Note: The 2014 drug lists may not apply for all members. Please call customer service to confirm your correct drug list.

A Drug List is a list of preferred drugs that are available to BCBSTX members. These drugs are considered to be safe and cost-effective. How much you pay out-of-pocket for prescription drugs is determined by whether your medication is on the list. Within a Drug List, generally the lower the tier, the lower the cost of the drug.

The formularies below are used for BCBSTX health plans that are offered through your employer. These health plans are not a "metallic" health plan and were effective before January 1, 2014.

If your company has 1-50 employees, your prescription drug benefits through BCBSTX may be based on the Preferred Drug List or the Generics Plus Drug List. The Generics Plus Drug List is a smaller version of the Standard Drug List. It includes mostly generic drugs and fewer brand-name drugs. The Generics Plus Drug List covers drugs for the major drug classes.

These updated drugs lists apply starting January 1, 2014:

Search Drug List and Find a Pharmacy

If your health plan includes BCBSTX prescription drug benefits, these are administered by Prime Therapeutics, the pharmacy benefits manager (PBM).

Visit Prime Therapeutics  to:

  • Search for prescription drugs
  • Find a pharmacy
  • Order mail service refills or new prescriptions online
  • View status of coverage for your drugs
  • Download forms and brochures
  • Get drug cost estimates
  • Learn more about drug side effects or interactions

BCBSTX has a broad network of contracting pharmacies. To use your benefits, simply find a contracting pharmacy close to you and present your member ID card.

Specialty Pharmacy Program

Your prescription drug benefit may include a specialty pharmacy program through Prime Therapeutics Specialty Pharmacy (Prime Specialty Pharmacy).

Specialty medications are those used to treat serious or chronic conditions. Examples include hepatitis C, hemophilia, multiple sclerosis and rheumatoid arthritis. These drugs are typically given by injection, but may be topical or taken by mouth. They often require careful adherence to treatment plans, have special handling or storage requirements, and may not be stocked by retail pharmacies.

When you purchase specialty medications through Prime Specialty Pharmacy, you can have your self-administered specialty medications delivered directly to you, or to your doctor’s office. You also receive at no additional charge:

  • Support services for managing your drug therapy
  • Educational materials about your particular condition
  • Help with managing potential medication side effects
  • 24/7/365 customer service phone access

Note: Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC, a pharmacy benefit management company. BCBSTX contracts with Prime Therapeutics to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSTX, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

Mail Service Program

PrimeMail®, the mail service pharmacy for members with BCBSTX prescription drug coverage, provides safe, fast and cost-effective pharmacy services that can save you time and money. With this program, you can obtain up to a 90-day supply of long-term (or maintenance) medications through PrimeMail. Maintenance medications are those drugs you may take on an ongoing basis to treat conditions such as high cholesterol, high blood pressure or diabetes.

Ordering Through PrimeMail

  • When you log in to Blue Access for Members and visit your Rx Drugs page, you can use the online order form, print an order form to mail or ask that PrimeMail get in touch with your doctor to request a new prescription.

For more information about using mail service:

Vaccine Program

If you have coverage through Blue Cross and Blue Shield of Texas, vaccinations may be covered under the medical benefit or the prescription drug benefit, based on your plan. Flu vaccinations can be conveniently administered at a pharmacy near you. Help protect you and your covered family members from the flu by getting the flu shot.

Please check your benefit materials for details and any necessary copays. Or, you can call the Pharmacy Program number on the back of your ID card.

  • The flu shot covered under the prescription drug benefit can be conveniently administered at a participating vaccine network pharmacy. Just hand your ID card to the pharmacist.
  • To see a complete list of all participating pharmacies, log in to Blue Access for Members and select Prescription Drugs from the Quick Links section on the right-hand side. Or, you can call the number on the back of your ID card.
  • Before you go, be sure to confirm the location's participation and hours, vaccine availability and ask about any other age limits, restrictions or requirements that may apply.

More information is available in the pharmacy vaccine program member flier .