Blue Cross Blue Shield of Michigan / PPO Drug Lists

Custom formulary

Use with triple-tier or closed (managed) plans only.

A triple-tier plan has three fixed copays, one for each tier of drugs. A closed or managed plan only covers Tier 1 and Tier 2 drugs. Learn more about tiers in the How do I know if my plan covers my prescription drug? article in our Help Center.

If you're not sure whether your plan uses the custom formulary, check your prescription drug benefits or call Customer Service at the number on the back of your enrollee ID card.

• Custom Formulary Quick Guide for Members (PDF)
• Custom Formulary (complete) (PDF)
• Custom Formulary Updates (PDF)
• Custom Formulary Lookup Tool: use this tool from Medco Health to find out the tier of any medication in the Custom Formulary. 
• Custom Formulary Prior Authorization/Step Therapy Drug List (PDF)

Clinical formulary

A comprehensive drug list. If you're not sure whether you should use the clinical formulary, check your prescription drug benefits or call Customer Service at the number on the back of your enrollee ID card.

• Clinical Formulary (PDF)
• Clinical Formulary Updates (PDF)
• Clinical Formulary Prior Authorization/Step Therapy Drug List (PDF)

Other helpful documents

Quantity Limit Program Drug List (PDF)
A list of drugs that have 30- and 90-day quantity limits.

Specialty Drug Program Member Guide (PDF)
A list of drugs used to treat complex and chronic illnesses that require special handling. The guide also includes the enrollment form for ordering specialty drugs from Walgreen's Specialty Pharmacy.

15-Day Specialty Drug Limitation Program List (PDF)
Members can only get a 15-day supply of these drugs when trying them for the first time.

Formulary Alternatives (PDF)
If a drug you've been prescribed isn't in our formulary, your doctor can use this list to find an alternative.

Related Items

• Blue Care Network / HMO Drug Lists
• How to read a drug list
• How do I know if my plan covers my prescription drug?
• Why do I need prior authorization for a prescription drug?