This information applies only to Blue Cross® Blue Shield® of Arizona (BCBSAZ)
customers with a standard Three or Four Level Copay Pharmacy Benefit. If you have
questions about your prescription medication benefits, please refer to your benefit plan
booklet and benefit schedule page. You may also call (602) 864-4273 or (800) 232-
2345, ext. 4273.Information is also available online to registered users of BlueNet
Online Services. Click here to register or learn more about BlueNet.
Medication Levels and Cost-Sharing for Prescription Medications
Depending on which specific benefit plan you have, the retail and Mail Service pharmacy benefit
has three or four cost-share (copay) levels. Copay amounts are listed on your schedule page.
BCBSAZ classifies prescription medications into one of four levels that correspond to copay
levels. Your copay amount will depend on the specific medication dispensed by the pharmacy
and the level to which the medication is assigned when you fill your prescription. If your plan has
only three copay levels, you will pay the Level 3 copay for medications placed on Level 4. Some
benefit plans have cost share requirements in addition to the copays. Depending on your plan,
you may have a prescription deductible (as explained below), an out-of-pocket maximum, and / or
a prescription maximum benefit. Your benefit plan booklet and schedule page will tell you whether
you have other cost share obligations beyond the copay.
Prescription medications may change levels at any time without prior notice. To confirm the status
of a particular medication,
click here
for a list of Level 1 and 2 medications.
Click here for an
alphabetical list of Level 2 medications.
Click here for a sample listing of Level 3 medications.
(Due to the number of available medications, not all Level 3 medications are listed.)
Click here for
a list of Level 4 medications. You can also call (602) 864-4273 or (800) 232-2345 ext. 4273 to
confirm the status of a particular medication.
Most generic medications are assigned to Level 1. BCBSAZ cannot guarantee that generic
medications will be available when you fill your prescription. If your provider has allowed generic
substitution, but a generic medication is not available, you will have to pay the copay for whatever
medication is dispensed. 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. If you or your provider
have specific questions regarding the availability of a generic medication, please contact the
dispensing 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
right for you.
Retail and Mail Service Pharmacy Network
Click here to view a list of participating network pharmacies with BCBSAZ. This list is
subject to change at any time without prior notice.
If your plan has an out-of-network pharmacy benefit, and you fill a covered prescription at a noncontracted
pharmacy, you must pay for your prescription in full and submit a claim to BCBSAZ. If
your plan does not have out-of-network pharmacy benefits, you must use network pharmacies
except for emergencies. When BCBSAZ processes your prescription claim from a noncontracted
pharmacy, and you qualify for covered benefits, 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
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billed charges and the BCBSAZ allowed amount.
Click here for the Prescription Medication
Reimbursement Form.
Precertification for Retail and Mail Service Pharmacy Benefits
Precertification is required for certain medications, including some medications covered
through the Retail and Mail Service Pharmacy Benefits. Please
click here for a list of
prescription medications that require precertification.
Click here to view the form that
prescribing providers may use to request precertification for Retail and Mail Service
Pharmacy Benefits. The list of 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.
Prescription Medication Limitations for Retail and Mail Service Pharmacy Benefits
BCBSAZ applies limitations to certain prescription medications obtained through the retail and
mail service 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.
Click here for a list of prescription medications subject to
BCBSAZ prescription medication limitations for Retail and Mail Service Pharmacy
Benefits.
For certain prescription medications, BCBSAZ applies a per-copay quantity limitation. Members
pay an additional copay each time the prescribed quantity exceeds the BCBSAZ per-copay
quantity limitation. If your provider prescribes more than the per-copay quantity limitation, you
may buy the prescribed amount up to any refill limit, but you will have to pay an additional copay
each time you exceed the quantity limitation. If the prescribed quantity is above the BCBSAZ
maximum quantity for a 30-day supply (retail) or 90-day supply (Mail Service), refill limitations will
also apply. Prescription medication refills are covered when approximately ¾ of the medication is
used as prescribed.
More Information About Your Retail and Mail Service Pharmacy Benefits
When the prescription medication price is less than the copay at a contracted pharmacy, you will
never have to pay more than your copay. However, some pharmacies may charge you a lower
price if the pharmacy's regular price for the medication is less than your copay.
Benefits and cost share for covered prescription medications may differ, depending on where you
obtain a medication (e.g., from a retail pharmacy, specialty pharmacy, in a physician's office,
through home health services).
Retail pharmacy and Mail Service prescription medication expenses typically do not apply toward
any applicable medical benefit plan out-of-pocket coinsurance maximum.
Retail and Mail Service Pharmacy Benefits for Injectable Medications
Only certain injectable medications are covered under the Retail and Mail Service
Pharmacy benefits. Other injectable medications may be covered under your medical
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benefit (such as Home Health benefit or Specialty Self-Injectable Medication benefit).
See your benefit plan booklet for additional information about these benefits.
Click here for a list of injectable medications available through your retail and Mail
Service pharmacy benefits. This list is subject to change at any time without prior notice.
Deductible for Prescription Medications Obtained Under the Retail and Mail-Order Pharmacy Benefit
Some plans have a prescription deductible for Level 2, 3, and 4 prescription medications. With
these plans, copays will not apply to any Level 2, 3, or 4 medications until you satisfy the
deductible.
Benefit Limitations and Exclusions for Retail and Mail Service Pharmacy Benefits
The fact that a medication is recommended or prescribed by a physician does not make
it a benefit. Benefit plans do not cover all health care expenses and have exclusions and
limitations which may include pre-existing condition waiting periods and waivers. All plans
generally exclude coverage for medications that are experimental, investigational, cosmetic for
treatment of sexual dysfunction, or which BCBSAZ deems not medically necessary. In addition to
these general limitations and exclusions medications are subject to certain other exclusions,
including over-the-counter drugs and drugs used for weight loss; lifestyle, fitness, or performance
enhancement; and treatment of fertility and/or infertility.
For complete information on your prescription medication and medical benefits,
coverage limitations and exclusions, refer to your benefit plan booklet.
Links to Information About Retail and Mail Service Pharmacy Benefits
Specialty-Self Injectable Medications and Home Health Injectable Medications
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