There are thousands of medications on the market, with more becoming available every day. Whether they’re prescribed to lessen symptoms of an illness, treat or cure a disease or help manage chronic conditions, knowing you can get the medication you need is important. But a visit to the pharmacy can quickly become frustrating if everyone involved in your care isn’t on the same page. Sometimes coverage of a prescription you’ve used for a long time is dropped in favor of a generic or your pharmacist tells you there’s a prior authorization required for a prescription your doctor wrote. In this post, we’re breaking down some of those frustrating pharmacy experiences to explain why they happen, how they ultimately help our members and how Blue Cross Blue Shield of Michigan works hard to make sure you get the safest, most effective and most reasonably priced prescription drugs.
What do you mean it’s not covered?
If you’ve ever tried to fill a recurring prescription only to have your pharmacist tell you it’s no longer covered at the same amount by insurance, we understand how frustrating that can be. The list of drugs we cover based on your plan is called a formulary or drug list. It’s a list of FDA-approved prescription drugs, both generic and brand name, that have been reviewed for safety, efficacy and cost effectiveness by our Pharmacy and Therapeutics committee. These drug lists vary by plan type and some can be updated frequently – as often as once a month in some cases. Drugs are often tiered on the list, giving preference to generic drugs, which are less expensive but just as effective. As generic versions become available, your name-brand prescription drug can change to a different tier or not be covered. To avoid surprises at the pharmacy or to see if there’s a generic version of a brand-name drug you’re currently taking that could save you money, log in to your member account at bcbsm.com or use the Blue Cross app to check our drug lists any time.
My friend and I were prescribed the same medication. Why is his covered and mine isn’t?
It’s all tied to the drug list linked to your specific plan. If you both have employer-based coverage, your plan options and drug lists could be very different. It’s important to understand your plan’s unique drug benefits so that you’re not surprised by unexpected costs and can work with your health care provider to make the best choices based on your situation and need for specific prescriptions.
Prior authorization? Step therapy? Why do I have to jump through these hoops?
Sometimes we take extra steps to ensure that a prescription is the right fit for a member. We do this through prior authorization and step therapy to ensure you’re getting a safe, effective prescription at a reasonable cost.
- Prior authorization is a required review of certain medications before your plan will cover them. We want to make sure that you’ve tried preferred alternatives – medications with a proven track record that may be better tolerated, less expensive or less likely to cause interactions – and that the medicine is being prescribed appropriately. If your doctor doesn’t get prior authorization when required, your medicine may not be covered. You should consult with your doctor about an alternative therapy in those cases.
- With step therapy, the Blue Cross pharmacy team performs an automated review of your medication history to determine whether you’ve first tried the preferred alternatives for your condition. This ensures all clinically sound and cost-effective treatment options are tried before more expensive medicines are prescribed.
Prior authorization and step therapy are tools we use for medications that:
- Have dangerous side effects or that can be harmful when combined with other medications
- Should only be used for certain health conditions
- Are often misused or abused
- Are prescribed when less expensive medicines might work better
To find out if a certain medicine needs prior authorization or step therapy, simply log in to your member account at bcbsm.com or use the Blue Cross app. You’ll need to know the name, strength and dosage of your prescribed medication. Click on the My Coverage tab and select Prescription. Then, click on Price a drug and view additional benefit requirements. This link takes you directly to the Express Scripts website and its Price a Medication tool – follow instructions and you’ll get an alert if the medicine needs a coverage review for either prior authorization or step therapy. You can also check our drug lists or call the number on the back of your pharmacy coverage card for assistance.
Looking out for you
Blue Cross and Blue Care Network contract with 2,500 independent and retail pharmacies throughout Michigan and 69,000 pharmacies in the United States to provide members with prescription services. When it comes to prescription drugs, safety, efficacy and cost are our guiding principles. Some of the methods we employ to achieve these goals may seem cumbersome and hard to understand, but rest assured our pharmacy team is actively fighting back against increasing drug costs in a variety of ways, and also working hard to ensure member safety in every way possible. If you found this post helpful, read these:
- Saved by a Pharmacist
- Mail-Order Prescriptions: Better for Your Health and Budget
- National Pharmacist Day Recognizes Important Team Care Approach
Photo credit: Gilgatron