Pharmacy Programs

The prior authorization/step therapy program is designed to encourage safe, cost-effective medication use.

This program may be part of your prescription drug benefit plan. To find out if your specific benefit plan includes the prior authorization/step therapy program, and which drugs are part of your plan, refer to your benefit materials, or call the number on the back of your ID card.

Prior Authorization

Under this program, your doctor will be required to request pre-approval, or prior authorization, through Blue Cross and Blue Shield of Texas (BCBSTX) in order for you to get benefits for the select drugs.

• Examples of drug categories and specific medications for which a prior authorization program may be included as part of your prescription drug benefit plan are listed below.
• Please note that not all drug categories are included in all benefit plans. Additional drug categories may be added and the medications listed are only examples. Call the number on the back of your ID card with questions about a specific medication.
• If you are taking, or prescribed, a drug that is newly introduced to the market on or after October 1, 2015, you may need to have your doctor submit a prior authorization request in order to get benefits for such drugs. If you have questions about your medicine, call the number on the back of your ID card.
• As always, cost is only one factor in choosing medication and treatment decisions are between you and your doctor.
• Prior Authorization Program for Members on a “Metallic” Health Plan
• Prior Authorization Program for Members on the Basic or Enhanced (Quarterly and Annual) Drug Lists
• Prior Authorization Program for Members on the Balanced Drug List
• Prior Authorization Program for Members on the Performance (Quarterly and Annual) Drug List
• Prior Authorization Program for Members on the Performance Select Drug List

Step Therapy

The step therapy program requires that you have prescription history for a "first-line" medication before your benefit plan will cover a "second-line" drug.

• A first-line drug is recognized as safe and works well in treating a specific medical condition, as well as being a cost-effective treatment option.
• A second-line drug is a less-preferred or likely a more costly treatment option.

Step 1: If possible, your doctor should prescribe a first-line medication right for your condition.

Step 2: If you and your doctor decide that a first-line drug is not right for you or is not as good in treating your condition, your doctor should submit a prior authorization request for coverage of the other drug.

• Below are examples of drug categories and specific medications for which a step therapy program may be included as part of your prescription drug benefit plan.
• Step therapy does not apply to the generic equivalents for these medications (if available), so if you and your doctor decide the generic equivalent is best for you, prior authorization is not required.
• These medications are listed along with the first use approved by the U.S. Food and Drug Administration, but may be prescribed for conditions other than those noted and would still be part of the step therapy program.
• Please note that not all drug categories are included in all benefit plans. Additional categories may be added and the medications listed are only examples. Call the number on the back of your ID card with questions about a specific medication.
• As always, cost is only one factor in choosing medication and treatment decisions are between you and your doctor.
• Step Therapy Programs for Members on a "Metallic" Health Plan
• Step Therapy Programs for Members on the Basic or Enhanced (Quarterly and Annual) Drug Lists
• Step Therapy Programs for Members on the Balanced Drug List
• Step Therapy Programs for Members on the Performance (Quarterly and Annual) Drug List
• Step Therapy Programs for Members on the Performance Select Drug List

If you have questions about the prior authorization/step therapy program, call the number on the back of your BCBSTX ID card.

Specialty medications are those used to treat serious or chronic conditions. Examples include hepatitis C, hemophilia, cancer and multiple sclerosis. They often require careful adherence to treatment plans, have special handling or storage needs, and may only be stocked by select pharmacies. More information is available in the specialty pharmacy program member flier .

You can download Specialty Pharmacy Program Drug List which includes a reminder about coverage for self-administered specialty medications.

A split fill program may apply to some specialty medications like select oral oncology (cancer) drugs. This program lets you try the medication first to make sure you can tolerate any potential side effects. You will get a partial fill of your prescription and only pay for what was filled (a prorated cost of your benefits).

Coverage benefits and requirements may vary based on your plan benefits. Call the number on your Member ID card if you have any questions.

To order through Accredo:

• For new prescriptions — Ask your doctor to call in your prescription to 833-721-1619 or e-prescribe your prescription to Accredo . Your doctor can find e-prescribing information on their website.
• For existing prescriptions — You can request a transfer of your existing prescription for a specialty medication by calling 833-721-1619.

A specialty pharmacy coordinator will contact you to confirm you correct mailing address and arrange delivery of your covered medications.

When you purchase specialty medications through Accredo, 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

BCBSTX members who use oral oncology or hemophilia specialty drugs may have other in-network specialty pharmacy options. Log in to your Blue Access for Members^SM account to find a preferred specialty pharmacy near you.

Accredo is a specialty pharmacy that is contracted to provide services to members of BCBSTX. The relationship between Accredo and BCBSTX is that of independent contractors. Accredo is a trademark of Express Scripts Strategic Development, Inc.

Prime Therapeutics LLC is a pharmacy benefit management company, contracted by BCBSTX to provide pharmacy benefit management and related other services. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics LLC.

Express Scripts^® Pharmacy, 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 Express Scripts^® Pharmacy. Maintenance medications are those drugs you may take on an ongoing basis to treat conditions such as high cholesterol, high blood pressure or diabetes. Download the maintenance drug list to check if your medication is included.

Ordering Through Express Scripts^® Pharmacy

Getting Started Online

You have more than one option to fill or refill a prescription online or from a mobile device:

• Visit express-scripts.com/rx . Follow the instructions to register and create a profile.
• Log in to myprime.com and follow the links to Express Scripts^® Pharmacy.

Order Over the Phone

Call 833-715-0942, 24/7, to refill, transfer a current prescription or get started with home delivery. Please have your member ID card, prescription information and your doctor’s contact information available.

Through the Mail

To send a prescription order through the mail, log in to Blue Access for Members. Complete the mail order form. Mail your prescription, completed order form and payment to Express Scripts^® Pharmacy.

For more information about using mail order, you can:

• Download the Express Scripts^® Pharmacy flier
• Call the phone number on the back of your member ID card

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. Select vaccines can be conveniently administered at a pharmacy near you. These vaccines can help protect you from illnesses such as the flu, pneumonia, shingles, hepatitis B, meningitis, HPV, tetanus, diphtheria and pertussis.

To learn more about which vaccines are available under your plan for you and your covered family members, check your benefit materials for details and any necessary copays. Or, you can call the phone number on the back of your member ID card.

• For vaccinations covered under the prescription drug benefit, select vaccines can be conveniently administered at a participating vaccine network pharmacy near you. Just hand your ID card to the pharmacist.
• To see a complete list of all participating pharmacies, search the pharmacy network on myprime.com and filter for vaccine pharmacies. 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 .

If you have BCBSTX prescription drug benefit coverage, you have access to our team of clinical pharmacists and other resource tools to help answer questions you may have about your prescriptions.

The Pharmaceutical Care Management (PCM) program helps you get the best results from the medicines you take. A member of the PCM team may reach out to talk with you about the medicines you take. The medication review by a clinical pharmacist helps make sure the medicines you are taking are safe and work well. The pharmacist can also share ways to help you lower your out-of-pocket costs for your prescriptions.

For more information about how PCM works:

• Download the PCM Program member flier .
• Call the phone number on your Member ID card.