How Can I Understand My Blue Care Network Prescription Drug Benefits?

When your doctor writes you a new prescription, you want to know whether your plan covers that drug and how much it will cost you. But where do you find that information?

First, you need 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 menu.
  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 visit our Pharmacy help section for more information.

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 included as a health care benefit, such as vaccines and other injectable drugs that are normally administered 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's a 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 menu.
  4. Click Prescription Drugs in the left-hand column.
  5. Click the link for Price a drug and view additional benefit requirements. 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:

  • Generic tier – this tier includes generic drugs. Members pay the lowest copay for generics, making them the most cost-effective options for treatment. The 6-Tier drug benefit splits generic drugs into two tiers:
    • The preferred generic tier includes generics and select brand-name drugs with the lowest copayment.
    • The nonpreferred generic tier includes generic drugs with a higher generic copayment.
  • Preferred brand tier - this tier includes preferred brand-name drugs. Because lower-cost or generic alternatives to these drugs are usually available, members pay more for these drugs.

  • Nonpreferred brand tier - this tier includes nonpreferred brand-name drugs for which there are either generic alternatives or more cost-effective, preferred brand-name drugs available. Members pay more for these drugs, and nonpreferred brand-name drugs are not covered for members with a closed benefit pharmacy plan unless the prescriber and BCN agree that the requested drug is medically necessary.

Managing your prescription drug benefits

Our online drug benefit tool 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
Still need help?

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Contact us

Blue Care Network - Prescription Drug Benefits

Magic: Blue Care Network is dedicated to providing affordable, quality health care for the people of Michigan. As part of our commitment, we're always looking for ways to help you get the prescription drugs you need, while keeping your costs low. This video will help you understand how to fill prescriptions, understand co-pays and coinsurance, learn about drug tiers, prior authorization and step therapies and find out if your prescription drugs are covered.

Tuewanda: To fill your prescriptions, simply go into a participated network pharmacy. Present your Blues ID card [and] you may have the option of receiving up to a 90-day supply, depending on the way your prescription is written.

To find out if you're eligible for a 90-day supply, simply consult with your pharmacist, refer to your member handbook or call our customer service lines.

Tom: The cost associated with your prescription coverage may be either a fixed copay or a coinsurance. A fixed copay is just that it's a fixed amount of the total cost of the drug. A coinsurance is a percentage of the total cost of the drug. So, for example, if the drug total cost were $100, your plan may have a $10 copay. If you had a coinsurance, that coinsurance may be 25% for example, which then your cost would be $25.

Christina: To help reduce your out-of-pocket expenses our dedicated team of board-certified doctors and licensed pharmacists choose medications that are safe and effective, and offer you the best value. These medications are put on our drug lists.

We use lists that group drugs into categories, called tiers. All medications are FDA-approved brand-name and generic drugs. Your out-of-pocket cost is determined by the tier a drug is on. The most cost-effective drugs are in the lower tiers, so the lower the tier, the less you'll pay out-of-pocket.

Richard: Generic drugs are equivalent to brand-name drugs and have the same active ingredients and strengths. Many times, the generic drugs are made by the same company that makes the brand-name drugs and they cost less. Generic drugs have a lower copay, so it saves you money.

Rinell: One of the things that I'm most proud about at the Blues is that we strive to provide our members with low out-of-pocket costs. And doing so, we provide coverage for most generic prescription drugs.

Richard: We review the use of certain drugs to make sure you receive the most appropriate and cost-effective drug therapy. These reviews are called prior authorization and step therapy.

Tom: Prior authorization means that you must meet certain clinical criteria or other information must be provided before we can approve coverage for a drug. For example, we may cover a drug only when it's used for a specific condition.

Christina: Step therapy means that, before we can approve coverage for a drug, you may need to try one or more equally safe and effective preferred drugs first. For example, you may need to try a generic drug first. If that option doesn't work, you may be able to step up to a drug that's on a higher tier.

Narrator: You can find out whether your prescription is covered on bcbsm.com.

Log in to your account. Once you've signed in, you'll find a comprehensive drug list under the My Coverage tab at the top of the screen. You'll also find answers to commonly asked pharmacy questions in our online Help Center. Remember, you can always call our customer service team, too. The member handbook is another great resource that explains your prescription drug benefit with information on coverage and how to fill prescriptions. As you scroll through the list of commonly prescribed drugs, remember, some prescription drugs may require prior authorization or step therapy.

Magic: If you have additional questions regarding tiers, prioritization, step therapy or your prescription drug coverage, please visit us at bcbsm.com or call our customer service team at the number on the back of your ID card and we'll be happy to assist you.

Other FAQ

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