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

Who is this for?

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 copayment information. To view a copy of your rider, log in to Member Secured Services. Click Manage my Plan, and select Certificates and Riders.

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 includd 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.

You can also find that information online through Member Secured Services.

After you've logged in, select the Hospitals, Physicians and Medications tab. The link to Medco Online Pharmacy will take you directly to Express Scripts (Medco's new name). You won't have to log in again.
In the left-hand column under “Prescriptions & benefits,” select “Price a medication” and follow the instructions.

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.