Is My Prescription a Pharmacy or Medical Benefit?

It’s no secret that prescription drugs can be pricey. Everyone wants to find ways to save on their medications. One of the best ways to save is to make sure you understand your health plan’s benefits and how they work. Knowledge is power, right?

There’s one question we often are asked: Is my prescription drug a pharmacy or medical benefit? In most cases, a prescription drug is covered under your pharmacy benefit. There are times, though, when a prescription drug is considered a medical benefit. Here is a breakdown to help you understand which is which.

Drugs That Fall Under Your Pharmacy Benefit

Think about the common medicines you pick up at your local drugstore or have delivered to your home. Drugs that help keep your blood pressure or cholesterol in check. The cream your dermatologist gave you for that itchy rash. Antibiotics for a sinus infection. Or insulin to manage your diabetes. They’re just a few examples of prescription medicines you can take yourself that may be part of your pharmacy benefit.

Drugs That Are a Medical Benefit

Sometimes, medications must be given by a care provider in a health care setting. Birth control implants are one example. So are chemo infusions for cancer and immunotherapy for complex and chronic diseases. These types of medications usually require patients to be monitored by a medical professional during their treatment. Your medical benefit may cover the cost of the medication and its administration.

Some Drugs Can Be Both

Vaccines given as part of preventive health care can be a pharmacy benefit or a medical benefit. A flu shot is the most common example. Its classification depends on your health plan and where you get the vaccine. Did you go to your local retail pharmacy for your flu shot? Or did your primary care provider give you a flu shot during your annual wellness check? The details determine which benefit category the flu shot may fall under. 

Of course, understanding the details of your Blue Cross and Blue Shield of Texas (BCBSTX) plan is one of the best ways to get the most out of your pharmacy benefit. Here are some things you can do:

Check Your Plan’s Drug List

The list is exactly what the name suggests – a list of prescription drugs covered by your health care plan. The list is organized into different levels of coverage called member payment tiers. Some plans may have four tiers. Others can have up to six tiers. Each tier has its own cost. The lower the tier, the lower your out-of-pocket costs will be for the drug.

Generic drugs are usually found in the lower tier. Name brand drugs and specialty drugs are often in higher tiers. You may pay more for a brand name drug if a generic equivalent is available.

Talk with your doctor and pharmacist about all your medications. Always check to see if they are covered under your health care plan. For any name-brand drug, ask if there are generics or lower-cost alternatives you can take. If your drug isn’t covered on your Drug List, ask if there are other covered options.

You can check your drug list when you go to bcbstx.com and log in to Blue Access for Members^SM (BAM^SM).

Be In-the-Know About In-Network Pharmacies

BCBSTX works with a broad network of pharmacies. When you use an in-network pharmacy, your out-of-pocket costs are often less. You may also be able to get up to a 90-day supply of covered drugs you use regularly.

Understand Special Requirements and Limits

Sometimes, you may need to meet certain criteria before your prescription drug coverage is approved.

• Members who use a specialty drug to treat a complex or rare condition may need to follow specialty pharmacy program guidelines.  
• Some drugs may have limits on how much medicine can be dispensed per prescription or in a given time span.
• Your doctor may need to get prior authorization before your drug is covered.
• You might need to try a more cost-effective drug first before moving to another drug covered through step therapy.

To review your pharmacy benefits, you can:  

• Go to bcbstx.com and log in to Blue Access for Members^SM to see in-network pharmacies and learn more.
• Call BCBSTX Customer Service at the number on your ID card.

Prime Therapeutics, LLC, is a separate pharmacy benefit management company contracted by Blue Cross and Blue Shield of Texas (BCBSTX) to provide pharmacy benefit management and related other services. In addition, contracting pharmacies are contracted through Prime Therapeutics. The relationship between BCBSTX and contracting pharmacies is that of independent contractors. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.