Pharmacy Programs for HMO Members

Medications with an equivalent available over-the-counter (OTC) are usually not covered through Blue Cross and Blue Shield of Illinois (BCBSIL) prescription drug plans.

Some facts to consider:

• You will not usually receive coverage for brand and generic prescription medications that have OTC versions available at the same prescription strength.
• You may still purchase the medication – either by prescription or over-the-counter – but you will be responsible for the full cost of the drug.
• Choosing to purchase the OTC version will often save you money.
• To see if a specific drug is part of the program, view the over-the-counter equivalent exclusion program drug list .
• If you have questions about the program, call the Pharmacy Program number on the back of your ID card.
• Talk with your doctor before making any changes to your current medication regimen. As always, treatment decisions are between you and your doctor.

This program does not apply to members who have outpatient prescription drug coverage through their medical plan, processed by BlueSCRIPT^SM.

The 90-day supply benefit program can save you both time and money. With this program, you have the option of obtaining up to a 90-day supply of long-term (or maintenance) medications through a network of contracting extended supply retail and mail service pharmacies. Maintenance medications are those drugs you may take on an ongoing basis to treat conditions such as high cholesterol, high blood pressure or diabetes.

• For more information, download the 90-Day Supply Program Member Flier .

Ordering Through ALLIANCERX WALGREENS PRIME

Getting Started Online

• Visit alliancerxwp.com/home-delivery . Follow the instructions to create a new account or sign in with your Walgreens.com username and password.
• Log in to myprime.com and follow the links to AllianceRx Walgreens Prime.
• You can also continue to use your Walgreens.com account.

Order Over the Phone

Call 877-357-7463, 24/7, to refill, transfer a current prescription or get started with home delivery. Please have your member ID card, prescription information and your doctor’s contact information available.

Through the Mail

To send a prescription order through the mail, log in to Blue Access for Members. Complete the mail order form. Mail your prescription, completed order form and payment to AllianceRx Walgreens Prime.

For more information about using mail service:

• Download the AllianceRx Walgreens Prime flier
• Call the phone number on the back of your member ID card

The prior authorization/step therapy program is designed to encourage safe, cost-effective medication use.

This program may be part of your prescription drug benefit plan. To find out if your specific benefit plan includes the prior authorization/step therapy program, and which drugs are part of your plan, refer to your plan materials, or call the number on the back of your ID card.

Prior Authorization

Under this program, your doctor will be required to request pre-approval, or prior authorization, through Blue Cross and Blue Shield of Illinois in order for you to get benefits for select drugs.

• Below are examples of drug categories and specific medications for which a prior authorization program may be included as part of your prescription drug benefit plan.
• Please note that not all drug categories are included in all benefit plans. Additional drug categories may be added and the medications listed are only examples. Call the number on the back of your ID card with questions about a specific medication.
• If you are taking, or prescribed, a drug that is newly introduced to the market on or after October 1, 2015, you may need to have your doctor submit a prior authorization request in order to get benefits for such drugs. If you have questions about your medicine, call the number on the back of your ID card.
• As always, cost is only one factor in choosing medication and treatment decisions are between you and your doctor.
• Prior Authorization Program for Members on a “Metallic” Health Plan
• Prior Authorization Program for Members on the Basic or Enhanced (Quarterly and Annual) Drug Lists
• Prior Authorization Program for Members on the Balanced Drug List
• Prior Authorization Program for Members on the Performance (Quarterly and Annual) Drug List
• Prior Authorization Program for Members on the Performance Select Drug List

Step Therapy

The step therapy program requires that you have a prescription history for a "first-line" medication before your benefit plan will cover a "second-line" drug.

• A first-line drug is recognized as safe and works well in treating a specific medical condition, as well as being a cost-effective treatment option.
• A second-line drug is a less-preferred or likely a more costly treatment option.

Step 1: If possible, your doctor should prescribe a first-line medication right for your condition.

Step 2: If you and your doctor decide that a first-line drug is not right for you or is not as good in treating your condition, your doctor should submit a prior authorization request for coverage of the other drug.

• Below are examples of drug categories and specific medications for which a step therapy program may be included as part of your prescription drug benefit plan.
• Step therapy does not apply to the generic equivalents for these medications (if available), so if you and your doctor decide the generic equivalent is best for you, prior authorization is not required.
• These medications are listed along with the first use approved by the U.S. Food and Drug Administration, but may be prescribed for conditions other than those noted and would still be part of the step therapy program.
• Please note that not all drug categories are included in all benefit plans. Additional drug categories may be added and the medications listed are only examples. Call the number on the back of your ID card with questions about a specific medication.
• As always, cost is only one factor in choosing medication and treatment decisions are between you and your doctor.
• Step Therapy Programs for Members on a "Metallic" Health Plan
• Step Therapy Programs for Members on the Basic or Enhanced (Quarterly and Annual) Drug Lists
• Step Therapy Programs for Members on the Balanced Drug List
• Step Therapy Programs for Members on the Performance (Quarterly and Annual) Drug List
• Step Therapy Programs for Members on the Performance Select Drug List

If you have questions about the prior authorization/step therapy program, call the number on the back of your ID card.

Specialty medications are those used to treat serious or chronic conditions. Examples include hepatitis C, hemophilia, cancer and multiple sclerosis. They often require careful adherence to treatment plans, have special handling or storage needs, and may only be stocked by select pharmacies. See the specialty pharmacy program member flier for more information.

A split fill program may apply to some specialty medications like select oral oncology (cancer) drugs. This program lets you try the medication first to make sure you can tolerate any potential side effects. You will get a partial fill of your prescription and only pay for what was filled (a prorated cost of your benefits).

Coverage benefits and requirements may vary based on your plan benefits. Call the number on your Member ID card if you have any questions.

BCBSIL HMO members can fill their self-administered specialty drug prescriptions at an in-network specialty pharmacy for pharmacy benefit coverage consideration. To find an in-network specialty pharmacy near you, log in to your Blue Access for Members^SM account and click on the Prescription Drugs link. This will take you to Prime Therapeutics, the pharmacy benefit manager. You can find a list of in-network specialty pharmacies for Illinois HMO members in the Forms section.

If you have BCBSIL prescription drug benefit coverage, you have access to our team of clinical pharmacists and other resource tools to help answer questions you may have about your prescriptions.

The Pharmaceutical Care Management (PCM) program helps you get the best results from the medicines you take. A member of the PCM team may reach out to talk with you about the medicines you take. The medication review by a clinical pharmacist helps make sure the medicines you are taking are safe and work well. The pharmacist can also share ways to help you lower your out-of-pocket costs for your prescriptions.

For more information about how PCM works:

• Download the PCM Program member flier .
• Call the phone number on your Member ID card.