Some drugs aren't covered
Prescription drug coverage does not include certain types of medications and medical supplies. Check your drug rider for details as your plan may have other exclusions. Drug riders do not cover:
- Cosmetic drugs or drugs used for cosmetic purposes
- Drugs that are not FDA approved or are being used for experimental or investigational purposes
- Prescriptions filled after you are no longer a member
- Drugs included as a health care benefit, such as vaccines and other injectable drugs that are normally administered in a physician’s office
- Drugs included as a benefit under Medicare or under any other health care program funded by federal or state government
- New drugs not yet added to the formulary
- Replacement prescriptions resulting from loss, theft or mishandling
- Drugs included in the cost of other services or supplies
- Drugs for which there are over-the-counter equivalents in both strength and dosage. (Note: BCN covers OTC Claritin (generic), Zyrtec and Prilosec OTC for the lowest copayment with a prescription from your doctor. These are listed in the formulary.)
- Durable medical equipment and supplies, such as inhaler spacer devices and blood glucose monitors
Brand-name drugs that physicians prescribe or members request to be dispensed as written, but are available as generics, are covered only when determined to be medically necessary by the physician and approved by Blue Care Network. This process encourages the use of equally effective generic drugs.
If a dispense-as-written prescription is authorized, you will be responsible for your usual copayment for the brand-name drug. If it is not authorized, you must pay the difference in cost between the brand-name product and the generic drug, in addition to your copayment for brand-name medications.
Most BCN prescription drug riders do not include coverage for nonformulary (Tier 3) drugs. If your drug rider does not include this coverage and your doctor determines that the nonformulary drug is the best treatment for you, your doctor may request authorization for coverage. Your doctor must call the pharmacy help desk to make that request. The request will be approved only if your physician and BCN agree that the requested drug is medically necessary and that a BCN Formulary Alternatives (41K PDF) cannot be prescribed. If the request is approved, you will only have to pay your usual copayment amount for the nonformulary drug.
page modified 09/23/2011