Drug benefit frequently asked questions
How do I know what my drug benefit is?
You have prescription drug benefits if you have a Blue Care Network prescription drug rider. Your drug coverage is explained in this rider to your BCN certificate. The prescription drug rider determines your drug plan and copayment level. If you can’t find your rider, call Customer Service at 1-800-662-6667 and ask about your copayment and the type of plan your group has purchased for you. A copayment is what you pay whenever you purchase a prescription.
Some members do not have a drug benefit as a part of their BCN coverage.
Are all drugs covered by my prescription drug benefit?
No. Some drugs are excluded from the BCN drug benefit. Examples of excluded medications include:
- Experimental drugs and drugs that have not been approved by the Food and Drug Administration
- Drugs that are covered under the medical certificate, such as vaccines and other drugs that must be administered in a physician’s office
- Replacement prescriptions due to loss, theft or mishandling
- Cosmetic drugs and products used for cosmetic purposes
- Over-the-counter medications, unless included in our Drug Formulary
In addition, some drugs require prior authorization and certain clinical criteria must be met before coverage is provided.
If your drug benefit is a two-tier closed formulary prescription drug rider, nonformulary drugs are not covered unless your physician and BCN agree that the nonformulary drug is medically necessary and that a Formulary Alternatives (PDF) would be detrimental to your health.
Am I required to order my prescription drugs through the mail?
No. If you have a BCN prescription drug rider, you can always go to your local pharmacy. Mail order is offered to you as a convenience and a savings.
How can I order medications by mail?
Visit Where to Fill Your Prescriptions
How can I order medications by mail if I need my medications right away?
Your doctor can provide you with two prescriptions — one for an initial 14-day supply and one for your mail-order supply.
Can I get more than a one-month’s supply of my medication from my local pharmacy?
You can order up to a 90-day supply of the medications you use regularly and pay only two copayments instead of three at a network pharmacy in Michigan. Certain drugs are not included in this program. BCN requires that eligible members first fill a prescription for a one-month supply of a new brand name medication to ensure the drug and dose are appropriate. Prescriptions for generic drugs are not be subject to this requirement.
Where can I get more information on my prescription drug benefits?
See your benefit certificate and rider.
How does BCN know if a doctor orders a drug that might conflict with another of my prescriptions?
BCN’s pharmacy claims system can identify most drug interactions that could result in a medication problem for our members. When a drug is prescribed that interacts with another prescription medication, the pharmacist must first contact your doctor to make sure that the combination is more important than the concern associated with the drug combination. You can learn more about medication safety in Medication Guides and Brochures.
What about generic drugs?
Visit Brand-Name Versus Generic
How does covering over-the-counter generic Claritin, Zyrtec and Prilosec OTC save money?
Over-the-counter Claritin, Zyrtec and Prilosec OTC are cost-effective alternatives to other medications on our formulary that provide the same type of relief. Members pay only the copayment they would normally pay for a generic drug for both over-the-counter generic Claritin and Zyrtec, antihistamines often used by people with allergies, and Prilosec OTC, a heartburn medication.
What do I need to do to purchase Claritin, Zyrtec or Prilosec OTC and have it covered by BCN?
To be covered, you will need to present a prescription from your physician to your pharmacist or ask your physician to telephone your pharmacist with authorization. You will pay your usual copayment for generic drugs.
Can I get reimbursed for a prescription medication?
If your prescription drug rider would normally provide coverage for the medication you purchased, then you can request reimbursement from BCN. The prescription must meet all of BCN’s requirements, and coverage will be based on your drug rider. Please complete and return the Medco Drug Reimbursement Form (PDF). If the request is reimbursable, you should receive your payment in 2-3 weeks.
page modified 09/23/2011