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Provider and Facility Reference Manual

Section 9 - Pharmacy


Blue Cross Blue Shield offers various riders to our members that cover prescription drugs. Benefits and co-payments may vary depending on the rider. Some contracts provide prescription drug coverage as a basic benefit.

The following will provide you with a general overview of the pharmacy benefits afforded to our members and programs that are in place to manage the benefit. These benefits may vary by plan.

Outpatient Managed Care Drug Benefits

Blue Cross Blue Shield offers both a Two-Tier Closed and a Three-Tier Managed Prescription Drug Benefit to members. Drugs administered or dispensed while the member is a patient in a hospital, nursing home, doctor's office, outpatient clinic or other institution are not covered under this benefit. The member, however, may be entitled to benefits under their basic medical contract.

With the Closed/Managed Formulary Benefit, physicians may prescribe drugs included on tiers 1 and 2 of the Blue Cross Blue Shield Drug Formulary. The Formulary promotes the safe and effective use of drug therapies by helping physicians select the drug product(s) considered most beneficial to their patient populations. Blue Cross Blue Shield promotes rational, scientific prescribing based upon consideration of published clinical studies, data from the United States Food and Drug Administration (U.S. FDA), community standards, and cost/benefit evaluation.

The Formulary contains a list of medications with preferred medications listed on tiers 1 and 2. It was developed and is maintained under the direction of our Pharmacy and Therapeutics (P&T) Committee. This committee consists of local physicians, community and health-system pharmacists, and other appropriate clinical professionals.

The goal of the Formulary is to improve the value of pharmaceutical care delivered through proper consideration of both quality-of-care and economic issues.

The P&T Committee evaluates, appraises, and selects those drugs considered to have the highest contribution to patient care from among the numerous pharmaceutical products available. Through a continuous improvement process, the P&T Committee performs therapeutic drug class and product specific evaluations to make recommendations that will allow us to maintain a clinically appropriate, cost-effective formulary. Criteria such as efficacy, safety, risk/benefit ratio, therapeutic outcome and cost are all included in the assessment process. Blue Cross Blue Shield providers are strongly encouraged to reference the Formulary for information on medication coverage. For the latest pharmacy information, visit our Find a Pharmacy page.

At the point of dispensing, the pharmacy will receive a message each time a non-formulary medication is being filled. If you prescribe a non-formulary medication, the pharmacist may contact you prior to dispensing to discuss formulary alternatives. Please consider the appropriateness of formulary treatment options for each patient. Many times a therapeutic switch can be made that will offer the patient the same outcomes to which they are accustomed.

The Three-Tier Drug Benefit provides greater drug selection by making both Formulary and Non-formulary medications available. These medications are divided into three tiers, with a copayment or coinsurance associated with each tier as follows:

  • First Tier: If a medication is a generic Formulary agent, this medication is listed in the first tier, with the lowest copay applied. As an exception, select inexpensive branded Over-The-Counter (OTC) agents may be placed on the first tier.
  • Second Tier: Preferred brand agents are placed in the second tier, having the middle copay.
  • Third Tier: If a brand name or generic medication is not on the Blue Cross Blue Shield Formulary, it will be listed in the third tier, with the highest copay applied. This may include brand name medications for which there are generics available, non-preferred brand agents and excessively priced generic agents.

Benefit Limitations

Both the Two-Tier Closed Formulary and the Three-Tier Drug Benefit have the following limitations:

Days’ Supply Limitation

In general, we will pay for up to a 30 calendar day supply of medication each time a prescription is filled or refilled at a retail pharmacy. We will cover up to a 90 calendar day supply of medication at a mail order pharmacy. Days’ supply limits may vary by benefit plan and by medication.

Refill Limitations

For chronic medications, we will pay for refills up to one year after the prescription was originally issued if so authorized by the prescriber. Applicable state medication dispensing laws may limit this allowance for federally scheduled medications, i.e., controlled substances.

Smoking Cessation

Highmark Blue Cross Blue Shield of Western New York members with preventive coverage have a pharmacy benefit to allow coverage of smoking cessation agents, both prescription and over-the-counter products. Cost of the products will be determined by the member's assigned co-pay.

Step Therapy

More cost-effective drugs should be prescribed whenever therapeutically feasible. In particular, step therapy is encouraged for classes of medication that contain multiple agents with similar effectiveness.  For example: intranasal steroids, migraine treatment, and urinary agents.

Exclusions

Certain medications may be excluded from coverage under a member’s benefit plan. In most cases, if a member attempts to fill a prescription for an excluded drug, they will have to pay the full retail price. Below is a sample list of drug exclusions:

  • Drugs that are generally administered by a health care professional
  • Products not approved by the U.S. Food and Drug Administration as a prescription drug  
  • Over-the-counter vitamins, with the exception of pre-natal and fluoride-containing vitamins
  • Drugs prescribed for cosmetic use
  • Prescription drugs when the product is available over-the-counter in the same strength and dosage form
  • Allergy extracts and vaccines

Please note that exclusions may vary by benefit plan. This list is not all encompassing and does not apply to all benefit plans.

Preauthorization Request Process

Our prescription drug and medical injectable policies promote safe and effective use by helping physicians select the drug product(s) considered most beneficial to their patients. In order to ensure thorough consideration of both quality-of-care and economic issues, some drugs require prior authorization to be covered under a member’s prescription drug or medical benefit. We work with a committee of local physicians, mid-level practitioners, and pharmacists to identify medications that should require prior authorization and to develop the medical criteria used to determine when coverage for these agents is appropriate.

Preauthorization will be based on specific medical criteria including dosage and the patient's condition. If preauthorization is not obtained, payment of the claim for the prescription will be rejected at the time the prescription is filled. The pharmacy will be notified through the on-line prescription claims processing system to contact the prescribing physician and advise him or her to obtain preauthorization.

Some medications administered under the medical benefit, such as injectables or implants, may require preauthorization.

Note: The preauthorization requirements must be followed for all managed care members. Physicians may request preauthorization by faxing the Preauthorization/Non-Formulary Request Form, ePrescribing, online at express-scripts.com, or by calling our Provider Service Department.

If you need a Preauthorization/Non-Formulary Request Form, log on to our secure provider dashboard to access the Medication Guide and Preauthorization/Non-Formulary Request Form, or contact Provider Service.

Non-Formulary Request Process

For members that have a Closed Formulary Benefit, coverage of formulary products may be available. If in the provider's professional judgment a non-formulary (3rd tier) agent is necessary, he/she must submit a non-formulary medication request form along with any supporting documentation to Blue Cross Blue Shield.

All requests for use of prior-authorization/non-formulary agents will be reviewed in a timely manner per New York State regulations and notification will be returned via fax, phone or mail.

To expedite the review process, please be sure to complete all information requested on the form.

  • Be sure that the writing is legible. Faxed copies are often more difficult to read.
  • Patient name, identification number and date of birth should always be included.
  • A complete list of medications previously tried by the patient, including samples dispensed from the provider's office, is required to accurately evaluate the request. Specific dosages prescribed, dates of service and/or reasons for discontinuation (i.e., ineffective, adverse reactions, unacceptable side effects) should also be provided.
  • If preauthorization / non-formulary criteria requires laboratory results, submit a copy of the lab report or document this information on your request.
  • Clearly note if the patient has any medical conditions or is taking other medications which limit the use of alternate formulary agents.
  • If insufficient information is provided, the request will be pended or denied and returned to you for additional information.

Drug Therapy Guidelines

Drug Therapy Guidelines are developed and updated under the direction of our P&T Committee. These guidelines are used to support coverage determinations for preauthorization requests. Notifications are routinely faxed to Blue Cross Blue Shield providers to help ensure medications are prescribed appropriately and in the most cost-effective manner. In each quarterly update, providers are directed to the guidelines published on our website. Participating providers are required to follow these guidelines when prescribing medications.

Outpatient Traditional Drug Benefits

Blue Cross Blue Shield offers various prescription drug riders to our members who have traditional/indemnity coverage. Benefits and co-payments vary depending upon the rider. Detailed information about prescription drug riders is included in the member's contract. Drugs administered or dispensed while the member is a patient in a hospital, nursing home, doctor's office, outpatient clinic or other institution are not covered under this benefit. The member, however, may be entitled to benefits under their basic medical contract.

We encourage you to refer to the Blue Cross Blue Shield Drug Medication Guide and Drug Therapy Guidelines for all members, including those who have traditional/indemnity coverage. Please visit our website for the most current Drug Formulary and Drug Therapy Guidelines.

Express Scripts®

Prescription drug benefits for Highmark Blue Cross Blue Shield of Western New York members are managed by Express Scripts, America's leading prescription drug benefit manager.

The Benefits of Express Scripts for our Members
Express Scripts offers a variety of services to our members, including:

  • Members may choose any pharmacy in the retail pharmacy network.
  • 24 hour customer service, 7 days a week (except Thanksgiving and Christmas)
  • 24 hour pharmacist support

Mail Order

Using Express Scripts® mail order pharmacy, members can obtain up to a 90-day supply of medication, usually for a lower copayment than for comparable retail prescriptions.

  • Members will ask for a new prescription for up to a 90-day supply, plus refills for up to one year (if appropriate).
  • The member will mail the new prescription using an Express Scripts mail order form and envelope supplied by Express Scripts.

 If necessary, members may ask for a second prescription for a 14-day supply to cover the time period between the request for mail order and its fulfillment. Please note that some medications are not eligible to be filled for a 90 day supply.