Blue Preferred Basic Plans

• Effective October 1, 2008 for Under-65 Individual BluePreferred Basic and BlueEssential Benefit Plans
• Effective January 1, 2009 for Group BlueSolutions Benefit Plans
• Effective January 1, 2009 for Group BluePreferred Basic Benefit Plans

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

Prescription medications can be covered through several different plan benefits. Coverage requirements and cost-share will vary, depending on the applicable benefit and the supply source of the medication.

The retail and mail-order pharmacy benefit has two cost-share levels, which are listed on your schedule page. For prescriptions obtained from an in-network retail pharmacy or the in-network mail-order pharmacy, you pay the lesser of the BCBSAZ price (the price for which BCBSAZ has contracted with the pharmacy) or the applicable brand or generic medication copay. When the pharmacy's standard retail price for the prescription is less than both of these amounts, the pharmacy may charge you this lower price. You will never pay more than your copay. Copays for generic medications will be lower than those for brand name medications.

Prescription medication limitations may change levels at any time without prior notice. You can check the list of prescription medications subject to BCBSAZ prescription medication limitations by calling the BCBSAZ Prescription Benefits Unit at the above numbers.

When you fill a covered prescription at a non-contracted pharmacy, you will pay for your prescription in full and submit a claim to BCBSAZ. When BCBSAZ processes your prescription claim from a non-contracted pharmacy, BCBSAZ will reimburse you based on the BCBSAZ allowed amount for the medication, minus any applicable cost share portion. In addition to your cost share, you will be responsible for the difference between the pharmacy's billed charges and the BCBSAZ allowed amount.

Please click here [PDF] to check a pharmacy's contract status with BCBSAZ. You can also call the BCBSAZ Prescription Benefits Unit at (602) 864-4273 or (800) 232-2345 ext. 4273.

Filing a Prescription Medication Claim

Please use these steps to file a prescription medication claim: Mail a copy of the itemized prescription receipt(s) to:

The receipt should include the patient's name and medication information, (medication name, the prescribing doctor's name, quantity, NDC number, pharmacy name and cost). Be sure to include your address and BCBSAZ subscriber identification number.

Precertification

Precertification is required for certain medications covered under the retail and mail-order pharmacy benefit. Please click here [PDF] for a list of prescription medications that require precertification. A list of medications that require precertification is also available by calling BCBSAZ at (602) 864-4273 or (800) 232-2345, ext. 4273. The list of specific prescription 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, the pharmacy may require you to pay for the medication when it is dispensed. In those cases, you may send BCBSAZ a claim for reimbursement. BCBSAZ will not deny such claims for lack of precertification, but will apply all other exclusions and limitations of your benefit plan.

Retail and Mail-Order Prescription 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, refill and gender limitations. BCBSAZ prescription medication limitations are subject to change at any time without prior notice.

For certain prescription medications, BCBSAZ applies a per-copay quantity limitation. These medications are subject to an additional copay each time the prescribed quantity exceeds the BCBSAZ per-copay quantity limitation. When your provider prescribes more than the per-copay quantity limitation, you may purchase the prescribed amount. However, you will have to pay an additional copay each time the quantity limitation is exceeded. If the prescribed quantity is above the BCBSAZ maximum quantity for a 30-day supply (retail) or 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.

Please click here [PDF] for a list of prescription medications subject to BCBSAZ prescription medication limitations. You can also check the list of prescription medications subject to BCBSAZ prescription medication limitations by calling the BCBSAZ Prescription Benefits Unit at (602) 864-4273 or (800) 232-2345, ext. 4273.

Mail-Order Pharmacy Program

In addition to your retail pharmacy benefit, you may also have a benefit for mail-order prescription medications, which will enable you to get up to a maximum 90-day supply. Please refer to your schedule page for copays and coinsurance amounts, as well as some of the limitations that apply to your plan's mail-order prescription benefit. Mail-order service is subject to all exclusions and limitations of your benefit plan, including prescription medication limitations.

More Information About Your Prescription Benefits

No exceptions will be made on the cost-share amount for a particular medication, regardless of the reason or condition for which it is prescribed.

Copays are based on whether the medication is brand or generic at the time the prescription is filled. No exceptions will be made concerning the copay or coinsurance that will apply, regardless of the medical reasons requiring use of a particular medication. This means if you are taking a brand medication, you pay the applicable copay for brand medications even when there is no equivalent generic medication or if you are unable to take a generic medication for any reason.

When the price BCBSAZ pays a contracted pharmacy for a medication is less than your copay, some contracted pharmacies will charge you the BCBSAZ price. However, most contracted pharmacies will charge you their regular retail price, if it is also less than your copay, rather than the BCBSAZ price. You should never be charged more than your copay at a BCBSAZ contracted pharmacy.

The fact that BCBSAZ has assigned a medication to a particular level does not guarantee coverage for that medication. Benefit plan limitations, exclusions and other factors determine if coverage is available for any specific medication.

Assignment of a medication to a particular cost-share level does not constitute a recommendation on the use of a medication. Always consult your provider to determine which medications are appropriate for you.

Benefits and cost share for covered prescription medications may differ, depending on where the medication is obtained (e.g., from a retail pharmacy, specialty pharmacy, in a physician's office, through home health services).

Retail pharmacy and mail-order prescription medication expenses do not apply toward any applicable medical benefit plan out-of-pocket coinsurance maximum.

Only certain injectable medications are covered under the retail and mail-order pharmacy benefit. Other injectable medications may be covered under your Home Health benefit or your Specialty Self-Injectable Medication benefit, subject to BCBSAZ medical necessity guidelines. See your benefit plan booklet for additional information about these benefits. Please click here [PDF] for a list of injectable medications available through the retail and mail-order pharmacy benefit. Injectable medication lists are also available by calling BCBSAZ at (602) 864-4273 or (800) 232-2345, ext. 4273.

Retail and Mail-Order Pharmacy Benefit Limitations and 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 stated within your benefit plan, in addition to the following specific limitations and exclusions:

• Administration of a covered medication
• Certain categories of injectable medications
• Compounded medications obtained from a mail-order pharmacy
• Immunizing agents and biological serums
• Medications, devices, equipment and supplies lawfully obtainable without a prescription
• Medication delivery implants
• Medications 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 member who is an inpatient in any facility
• Medications for athletic performance
• Medications for lifestyle enhancement
• Medications for sexual dysfunction
• Medications labeled "Caution - Limited by Federal Law to Investigational Use" or words to that effect and any experimental medications as determined by BCBSAZ, except as stated in your plan
• Medications obtained from an out-of-network mail-order pharmacy
• Medications packaged with one other or multiple other prescription products
• Medications packaged with over-the-counter medications, supplies, medical foods, vitamins or other excluded products
• Medications to improve or achieve fertility or treat infertility
• Medications used for any cosmetic purpose
• Medications used to treat a condition not covered under your plan
• Medications with primary therapeutic ingredients that are sold over the counter in any form, strength, packaging or name
• Prescription medications dispensed in unit-dose packaging, unless that is the only form in which the medication is available
• Prescription refills for medications that are lost, stolen, spilled, spoiled or damaged
• Smoking cessation medications and devices of any kind
• Specialty self-injectable medications

For complete information on your prescription medication and medical benefits, coverage limitations and exclusions, refer to your benefit plan booklet. All other exclusions and limitations of your benefit plan will apply.