To help you better understand our Pharmacy Program, here are answers to some frequently asked questions.

New ID cards must be issued whenever benefits change.  This might be the result of your employer's decision or a change in Massachusetts law.  Your ID card contains valuable information, including phone numbers and copay amounts, so be sure to read both sides carefully.  And always carry your ID card with you to show your pharmacist or doctor. 

Your doctor may request an exception from our Clinical Pharmacy Department to provide coverage for a non-covered drug when medically necessary.  If approved, the drug will require the highest level co-payment.  If the request is not approved, you will remain responsible for the full cost of the prescription.  You may use our standard member appeals process to request further review.

This is generally required in cases where the patient must meet certain medical-necessity criteria.  For certain drugs approved by the Food and Drug Administration (FDA) and included on our covered drug list, we require the physician to obtain prior authorization before we reimburse the cost of the prescription drug.  These drugs are listed in the formulary search.  Patients must have pharmacy benefits under their subscriber certificates that cover those drugs that require prior authorization.  See your plan sponsor for details. 

On an ongoing basis our Pharmacy & Therapeutics (P&T) Committee reviews the safety, effectiveness, and overall value of new drugs approved by the FDA.  While a new drug is being reviewed, it will not be covered by your plan.  This policy will not apply to members of our Medex^® and Medicare HMO Blue plans.  As with other non-covered drugs, your physician may request coverage for a drug under review when medically necessary. 

BCBSMA relies upon physicians practicing in Massachusetts to provide feedback on pharmacy program decisions.  This committee, made up of representatives of physician organizations in Massachusetts, reviews drug comparisons for clinical benefit, side effects, and relative cost.  The principal mission of the committee is to assure that our members have drugs covered, or available on an exception basis, that meet their needs and achieve desired treatment goals. 

To check if a certain drug is under review and not yet covered, call the Member Service number on the front of your ID card. 

PBM's, like the one we've partnered with, Express Scripts, Inc. (ESI), are companies that specialize in administering prescription drug benefit programs.  They also maintain an extensive retail pharmacy network to process your prescriptions.   Because of its size, a PBM can negotiate discounted prices from drug companies. 

• Throughout the last two decades, the use of medicines to treat illnesses ranging from allergies to heart disease increased greatly.  With that innovation came greater demand for brand name medicines. 
• During the same period, legislation has allowed drug companies to extend their patents on brand name drugs, which allows the drug maker to sell the drug exclusively for many years with limited competition. 
• Drug advertising regulations have loosened as well.  This has spurred expensive marketing campaigns for brand name drugs. 
• These television and magazine ads have raised people's awareness of new drugs, resulting in a rapid increase in the number of requests for expensive, brand name prescriptions. 

No.  The generic name of a drug is its chemical name.  The brand name is the trade name under which the drug is advertised and sold.  Generic and brand-name drugs must meet the same FDA standards for safety, purity, strength, and effectiveness.  In general, generic drugs will save you money.  So whenever possible, ask your doctor to prescribe generic drugs. 

If you take medications on a regular basis, our Mail Service Pharmacy is convenient and can save you money.  For most plans, you can order up to a 90-day supply through the mail usually for the same amount you would pay for a 30-day supply at your local pharmacy.  Plus, you can receive your medications through the mail, at home or at work, postage paid, within 14 days of mailing your prescription.  To learn more about our Mail Service Pharmacy, just call 1-800-262-BLUE and ask for a Mail Service Pharmacy brochure. 

In general, it's a good idea to plan ahead so that you don't have to worry about running out of your medications while on vacation.  The first step is to get a prescription from your doctor for the amount of the medication needed. 

If you're traveling within the U.S., and anticipate that your prescription will run out, ask your doctor for another prescription to take with you.  You can fill your prescription at any participating pharmacy in the U.S.  Our network consists of 94% of the pharmacies nationwide, including most major chains.  To find a participating pharmacy in the area in which you'll be traveling, call ESI Customer Service at 1-800-892-5119. 

If you are traveling out of the country, your pharmacist will know how to obtain authorization for a special supply. 

Yes, if you have a drug benefit you can fill your prescription at any participating pharmacy nationwide.  Our network consists of 94% of the pharmacies nationwide, including most major chains.  You can call the phone number on your ID card to find a participating pharmacy near you. 

Though you should always speak with your physician or pharmacist if you have specific questions about any prescription drugs, the Drug Database at AHealthyMe.com can give you instant up-to-date information on more than 4,000 prescription and OTC drugs including their interactions and side effects. 

A formulary is the list of drugs a health plan covers.  Ours contains more than 3,500 drugs.  It was developed by doctors and pharmacists after careful evaluation of clinical studies to determine which medications are most effective, safe, and maximize cost savings.  Most plans, like ours, also maintain a small list of non-preferred drugs.  The vast majority of the non-preferred drugs have one or more FDA-approved alternatives that are covered.  Our formulary allows us to offer you brand-name and generic drugs that meet your needs, at a reasonable cost. 

Quality Care Dosing is a program designed to ensure that the quality and dose of your prescription for certain medications meet FDA and other accepted clinical practice guidelines.  In cases where it doesn't, QCD offers modifications to bring quantity and dosage in-line with FDA recommendations.