How Can I Understand My Prescription Drug Benefits?
When your doctor writes you a new prescription, you want to know whether your Blue Cross Blue Shield of Michigan prescription 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:
- Log in to your account at bcbsm.com.
- Select My Coverage in the blue bar at the top of the page.
- Select Medical from the drop-down menu.
- Select Plan Documents in the row of tabs.
- 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 and find your formulary and drug lists.
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:
- Log in to your account at bcbsm.com.
- Go to My Coverage and then to the Prescription section and select Find a Pharmacy.
- 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
Check your costs and coverage online
The fastest way to find out what drugs we cover and how much you'll pay is by looking in your online account. Here's how.
- Log in to your account at bcbsm.com.
- Go to My Coverage.
- Choose Prescription Drugs.
Not registered? Sign up for an online account for access to your benefit information.
From there, you'll be able to find out what's covered, how much a medication will cost and compare brand-name prescriptions with generics.
What else you should know
Every PPO plan is different. You should check your member handbook to get information specific to your plan. In general, here are a few things you should know.
- Some plans don't count what you spend at the pharmacy toward your deductible.
- Most prescriptions have a copay. Your copays will usually be less for a generic drug than a brand name. It might be a certain dollar amount or a percentage of your total.
- Your medication might require step therapy or prior authorization.
Learn more about how to understand your Blue Cross pharmacy benefits (PDF).
