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How can I understand my Blue Care Network prescription drug benefits?

Who is this for?

Michigan Health Insurance – Customer Service – Pharmacy

If you have prescription drug coverage through Blue Care Network, this information will make it easier to figure out your benefits.

Your doctor writes you a new prescription. You want to know whether your health care plan covers the drug and how much you’ll have to pay for it at the pharmacy. But where do you find that information?

What you need is your prescription drug rider, a document that lists your benefits and your copay information. To view a copy of your rider,

  1. Log in to your account at bcbsm.com.
  2. Hover over My Coverage in the blue bar at the top of the page.
  3. Select Prescription Drugs from the drop down.
  4. Click Plan Documents in the left-hand column.
  5. Scroll down to the Certificates and Riders section.

What's covered

The Benefits section of your rider tells you what’s included in your prescription drug coverage. It may include things like approved drugs from the Blue Care Network drug list, insulin and contraceptives.

If you want to find out if a specific drug is covered by your plan, please see How do I know if my plan covers my prescription drug? for more help.

What's not covered

Blue Care Network prescription drug plans typically don’t cover:

  • Cosmetic drugs
  • Experimental drugs that aren’t FDA approved
  • New drugs that aren’t on our drug list
  • Replacements for lost, stolen or mishandled prescriptions
  • Drugs that have over-the-counter equivalents of the same strength and dosage
  • Drugs include as a health care benefit, such as vaccines and other injectable drugs that are normally adminsitered in a physician's office
  • Durable medical equipment and supplies, such as blood glucose monitors
  • Creams and other products approved as devices
  • Syringes and needles except for insulin syringes and needles when dispensed with insulin
  • Compounded products, unless there is clear medical necessity and all BCN criteria are met

Check the Exclusions section of your rider to find out exactly what your plan doesn’t cover. 

Your rider will also give you any limitations on your coverage. For example, some drugs may only be covered if they’re prescribed by a doctor in your network.

If we decline to cover a prescription drug, here's how you can appeal a pharmacy denial.

How much you'll have to pay

Our prescription drug plans require you to pay a fixed amount, or copay, when you fill a prescription. You can find your copay amounts in the Copayment/Coinsurance section of your rider.

Here's how to find that information online:

  1. Log in to your account at bcbsm.com.
  2. Hover over My Coverage in the blue bar at the top of the page.
  3. Select Medical from the drop down.
  4. Click Prescription Drugs in the left-hand column.
  5. Click the link for Price a drug and view additional benefit requirements. It will take you directly to Express Scripts (formerly Medco). You won't have to log in again.
  6. Enter the name of the drug and follow the instructions. You'll need to know the dosage and how often you'll be taking it. 

When you look up how much a drug will cost you, you’ll need to know which tier it belongs to:

  • Tier 1 (also called Formulary Preferred). Drugs listed as Tier 1 are preferred because they offer the best combination of effectiveness, safety and value. Most generic drugs are Tier 1.
  • Tier 2 (also called Formulary Options). Because less expensive or generic alternatives to these drugs are usually available, most Tier 2 drugs have a higher copayment.
  • Tier 3 (also called Nonformulary). Drugs not on the approved list. You may have a higher copayment for these drugs, or have to pay the entire cost.

Managing your prescription drug benefits

Our online drug benefit tool through Express Scripts makes managing your prescription drug benefits a breeze. You can use it to:

  • Find a pharmacy in your network
  • Print your prescription history
  • Review your Blue Care Network benefit highlights
  • Price medications
  • Check drug information
  • Reorder mail order prescriptions

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