Prescription Drugs Coverage

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Your pharmacy benefit is administered by a Pharmacy Benefit Manager (PBM) – CVS Caremark. PBMs are responsible for managing your prescription drug program. They act as a “middleman” between the prescription drug manufacturer and the pharmacy to help negotiate drug costs, process claims, and manage mail-order prescriptions. While the pharmacy benefit is administered by a separate company, it’s completely integrated with your BCBSTX medical plan. There’s lots of information on this page, but we recommend starting with Frequently Asked Questions.

Drug Lists

Note: Drug lists are subject to change. The latest information can always be found online and we recommend logging into www.Caremark.com to check coverage and copay information for a specific medication.

Formulary (Preferred) Drug List: List of medications covered under the Rx benefit. Generic should be considered the first line of prescribing. Preferred, brand-name medicines (ALL CAPS) are listed to help identify medications that are clinically appropriate and cost-effective. Generics are listed in italics and this is not an all-inclusive list.

HDHP Preventive Drug List: For the Union medical plan only – A list of medications considered preventive by the IRS under the Affordable Care Act (ACA), and therefore not subject to the medical/Rx deductible if enrolled in the High Deductible Health Plan (HDHP). HDHP members will be responsible for paying co-insurance based on the drug’s coverage tier (generic or preferred).

Specialty Drug List: List of medications used to treat complex or serious illnesses and disorders. These types of medication are filled through CVS Caremark’s Specialty Pharmacy. If you are currently taking a specialty drug, active prescriptions will transfer automatically to CVS Caremark. We recommend enrolling online at www.CVSspecialty.com to fill medications, estimate costs, and set up your payment method. Specialty medications tend to be very expensive and to ensure the medication being prescribed is clinically appropriate and to minimize waste, there are quantity limits on certain specialty medications – see list here.

Prudent Rx Specialty Drug List: Genesis has partnered with a third-party organization, PrudentRx, to offer cost savings for a subset of select specialty drugs. If a specialty drug qualifies for this program, the new co-pay will be $0 under the Choice Plus PPO and $0 under the Choice Saver HSA after the deductible is met. This partnership also allows Genesis to take advantage of discounts and rebates offered by the drug manufacturer(s). Terms and conditions are associated with this program. Information will be distributed directly to any plan member who takes a medication on the PrudentRx specialty drug list. 

Non-Formulary (Exclusion) Drug List: List of drugs or categories not covered under the plan; however, often there are different brand-name products or generic equivalents available in place of your original prescription that are equally effective. Should you choose to fill a non-formulary drug, you will be responsible for the full cost of the product.

Medications Requiring Prior Authorization: A list of medications that will not be covered without prior authorization for medical necessity. This list is primarily for newly prescribed medications that require prior authorization, or if prior authorization is not currently in place, then talk to your doctor about choosing from the formulary options available that do not require prior authorization.