Blue Preferred Saver Plans

Effective October 1, 2007 for Under-65 Individual Products

Effective beginning January 1, 2008 for new groups and upon each group's renewal

This information applies only to Blue Cross® Blue Shield® of Arizona (BCBSAZ) customers enrolled in a standard BluePreferred Saver plan. Please refer to your benefit plan or contract booklet for complete information on your prescription medication coverage. You may also contact the BCBSAZ Prescription Customer Service Unit at (602) 864-4273 or (800) 232-2345, ext 4273 for details of your coverage.

Benefits for covered prescription medications may differ depending on whether the medication is purchased at a pharmacy, administered in a physician's office, delivered through home health services or acquired under other coverage provisions of your benefit plan. All prescription medication benefits are subject to applicable exclusions and limitations of your benefit plan, and certain medications are subject to other limitations as described below.

Retail Pharmacy Benefit

You may obtain up to a 30-day supply of prescription medication through a retail pharmacy. When you fill a covered prescription at a BCBSAZ contracted retail pharmacy, the pharmacy will submit your claim to BCBSAZ. At the time the prescription is filled, you must pay the BCBSAZ price (the price for which BCBSAZ has contracted with the pharmacy) in full until your deductible is met. If the pharmacy is contracted with BCBSAZ, your cost will be based on the price that BCBSAZ has negotiated with that pharmacy. BCBSAZ will process the claim and apply the BCBSAZ allowed amount to your deductible. Even after you satisfy the deductible, you remain responsible for any coinsurance.

If you fail to present your BluePreferred Saver identification card at a contracted pharmacy, the pharmacy may charge you the full retail price for your prescription, and you will have to send BCBSAZ a claim for reimbursement. In this situation, BCBSAZ's reimbursement will still be based on the BCBSAZ price, not the pharmacy's retail price.

When you fill a covered prescription at a noncontracted pharmacy, you will pay for your prescription in full and submit a prescription medication claim to BCBSAZ. When BCBSAZ processes your prescription medication claim from a noncontracted pharmacy, you will be responsible for any applicable deductible, coinsurance or copay amount, plus the difference between the price charged by the pharmacy and the BCBSAZ allowed amount.

Filing a Prescription Medication Claim

To file a prescription medication claim, simply mail a copy of the itemized prescription receipt(s) to: BCBSAZ Prescription Customer Service Unit, Mail Stop A115, P.O. Box 13466, Phoenix, AZ 85002-3466. The receipt hould include your name and prescription medication information (medication name, the prescribing doctor's name, quantity, National Drug Code number, pharmacy name and cost). Be sure to include your address and BCBSAZ subscriber identification number.

Mail Order Pharmacy Benefit

You may obtain up to a 90-day supply of maintenance medications (the same medication and medication strength) through the prescription medication mail order benefit. Maintenance medications are medications you take consistently. A mail order benefit is only available through the contracted mail order provider and is not covered through a noncontracted provider. Payment must be made with a debit or credit card. Please refer to your schedule page for copays and/or coinsurance amounts.

Injectable Medications

Only certain categories of injectable medications are covered through the retail and mail order pharmacy benefit. Other injectable medications may be covered through the Specialty Injectable Medication benefit or the Home Health benefit, subject to BCBSAZ medical necessity guidelines. Precertification is required for both the Specialty Injectable Medication benefit and the Home Health benefit, and all other limitations and exclusions of your benefit plan or contract will apply. Click here for the list of injectable drugs covered through the Pharmacy Benefit or you may call the BCBSAZ Prescription Customer Service Unit at (602) 864-4273 or (800) 232-2345, ext. 4273 if you have questions regarding these injectable medications.

Cost Sharing

• You must satisfy your deductible before BCBSAZ will begin to pay for any covered prescription medication.
• For plans that have in-network coinsurance, when the price BCBSAZ pays a contracted pharmacy for a medication, or your coinsurance payment for a medication, is less than $5, most pharmacies will charge you their retail price (if also less than $5 or your coinsurance), rather than the BCBSAZ price or coinsurance payment. Some pharmacies may charge you the BCBSAZ price or your coinsurance payment when it is less than $5.
• Applicable coinsurance, copay and deductible amounts are applied to the out-of-pocket maximum.

Retail and Mail Order Pharmacy Benefit Medication Limitations

BCBSAZ applies limitations to certain prescription medications obtained through the retail and mail order pharmacy benefit. These limitations include, but are not limited to, quantity, age and gender limitations. BCBSAZ prescription medication limitations are subject to change at any time without prior notice.

Prescription medications that have quantity limitations are subject to additional cost sharing each time the amount prescribed exceeds the BCBSAZ per-prescription quantity limitation. When your provider prescribes more than the quantity limitation, you may obtain the prescribed amount. However, you will have to pay additional cost sharing each time the quantity limitation is exceeded. If it is above the BCBSAZ maximum quantity for a 30-day supply (retail) or up to a 90-day supply (mail order), refill limitations will also apply. Prescription medication refills are covered when approximately ¾ of the medication is used as prescribed.

Click here for the list of prescription medications subject to BCBSAZ prescription medication limitations, or you may call the BCBSAZ Prescription Customer Service Unit at (602) 864-4273 or (800) 232-2345, ext. 4273.

Precertification

Precertification is required for certain medications covered under the retail pharmacy and mail order benefits. For a list of medications that require precertification and the process for obtaining precertification, click here, or you may call the BCBSAZ Prescription Customer Service Unit at (602) 864-4273 or (800) 232-2345, ext. 4273. Otherwise covered eligible medications will not be covered if precertification is not obtained when required. The list of specific medications that require precertification is subject to change at any time without prior notice.

If precertification is required, but you must obtain the covered medication outside of BCBSAZ precertification hours, you may be required to pay for the medication at the time it is dispensed to you. In those cases, you may file a claim to BCBSAZ for reimbursement. BCBSAZ will not deny your claim for lack of precertification, but all other limitations and exclusions of your benefit plan or contract will still apply.

Retail and Mail Order Pharmacy Benefit Exclusions

The fact that a medication is recommended or prescribed by a physician does not make it a benefit. Prescription medication benefits are subject to all the limitations and exclusions in your benefit plan. The following are specifically excluded from coverage:

• Any medication, device, equipment and/or supply (except for diabetic supplies and inhaler spacers) that is lawfully obtainable without a prescription, i.e., over-the-counter items.
• Any vitamins, minerals, dietary and nutritional supplements, special foods or diets, except as stated in your benefit plan.
• Medications for off-label, unlabeled or orphan medications (orphan medications are used for diagnosis, treatment or prevention of a rare disease or condition) unless otherwise specified by BCBSAZ medical or prescription medication coverage guidelines. This exclusion does not include medications used for the treatment of cancer.
• Medications for sexual dysfunction.
• Medications to improve or achieve fertility or treat infertility.
• Performance, athletic performance or lifestyle enhancement medications or supplies.
• Smoking cessation medications or devices, regardless of whether a prescription is required.
• Immunizing agents or biological serums sold as separate items.
• Medication delivery implants.
• Administration of a covered medication.
• Any medication labeled "Caution - Limited by Federal Law to Investigational Use,” or words to that effect, and/or any experimental medication as determined by BCBSAZ, even though you would be charged for this medication.
• Any prescription medication dispensed in unit-dose packaging, unless that is the only form in which the medication is available.
• Any medication designed for weight gain or loss, including, but not limited to, Xenical® and Meridia®, regardless of the condition for which it is prescribed.
• Medications dispensed to a subscriber while an inpatient in any facility. To the extent facility coverage is available, medications are included in the reimbursement to the facility, and are not separately covered under "the Retail and Mail Order Pharmacy Benefit”. If the facility services are not covered, there is no coverage for medications dispensed at the facility.
• Prescriptions or refills for medications that are lost, stolen, spilled, spoiled or damaged.
• Any medication used for any cosmetic purpose, including but not limited to, hair growth or hair removal.
• Specialty self-injectable medications (such medications may be covered under other benefits, such as specialty injectable or home health).
• Any medication used to treat a condition not covered under your benefit plan or contract.

The following are excluded from coverage under the mail order pharmacy benefit:

• Compounded medications (may be covered under retail pharmacy benefit).
• Medications obtained from a mail order pharmacy not contracted with BCBSAZ to provide mail order prescription benefits.

For more information about your retail and mail order pharmacy benefits, coverage limitations and exclusions, please refer to your benefit plan or contract booklet. All other limitations and exclusions of your benefit plan or contract booklet will also apply.