Prescription Drug / Pharmacy Information

Pharmacy Information (image title)

2018 Formulary Information

The Blue Cross of Idaho formularies list drugs approved for coverage under your policy. The formularies include brand name as well as generic drugs that have undergone rigorous testing and are approved by the Food and Drug Administration (FDA). The formularies also provide information regarding the following:

  • Benefit Levels, also known as Tiers
  • Prior Authorization and/or Step Therapy requirements
  • Quantity or Age Limits

Most employer groups use one of three formularies. You can verify which formulary to use by checking the Prescription Drug Program section of your plan's Benefit Description, located under Benefits & Coverage after logging in.

Qualified Health Plan Formulary - 6 Tier for Metal Level Plans - For individual and small group Affordable Care Act plans that are available through the healthcare exchange at Your Health Idaho or directly through Blue Cross of Idaho.

If you are unsure about the formulary your plan uses, please contact CVS Caremark RX Customer Care at the number on the back of your Blue Cross of Idaho member ID card to check costs for prescription drugs.

Formulary Updates

How does a multi-tier formulary work?

In most cases, you are responsible to pay a portion of the cost of each prescription you have filled. Drugs are categorized into benefit levels, also known as tiers, which determine the amount you pay. Costs are lowest for first tier (generic) drugs, and costs increase as the tiers increase. In addition to the tiers, certain preventive drugs may be covered at no cost.

What will my prescriptions cost?

To obtain a cost estimate for prescribed medications, based on your current benefits and accumulations, complete the following steps:

  1. Log into your member account at members.bcidaho.com. (If you don’t have one, creating one is easy. You’ll need your Blue Cross of Idaho member ID card to get started.)
  2. Select Benefits and Coverage from the Prescription Drugs menu.
  3. Select Access Your Pharmacy Benefits Now – You will be redirected to the CVS Website.
  4. Select Check Drug Coverage and Cost from the Understand My Plan & Benefits menu.
  5. Follow the additional prompts to complete a Cost & Coverage check.

For questions regarding cost estimates obtained through the CVS website, or to obtain a cost estimate for your prescriptions over the phone, please contact CVS Caremark Rx Customer Care.

What is a specialty drug?

If you would like to know more about Specialty medications, please visit the Specialty Drugs page.

Why should I consider generic drugs?

Generic drugs are equivalent to brand-name drugs in dosage, safety, strength, route of administration, quality, performance characteristics and intended use. Although generic drugs are chemically the same as their branded counterparts, they are typically sold at substantial discounts from the branded price. The use of generic medications is a valuable way to reduce overall prescription drug costs without sacrificing quality.

You have the option to choose a brand-name medication when a generic equivalent exists. However, when a brand-name medication is chosen over an available generic equivalent, you will pay the cost difference between the brand-name and generic medications, in addition to the brand-name copayments.

What are quantity limits?

Some medications may have limits on how many doses are paid for by your policy. Limits are established with the manufacturers and the U.S. Food and Drug Administration’s (FDA) recommendations and accepted medical practices.

Quantity Limits for Qualified Health Plans are included in the formulary.

For all other plans, please review the Drugs with Quantity Limits or Restrictions List.

If your doctor or pharmacy told you a medication you were prescribed has a quantity limit and you have additional questions, please contact CVS Caremark RX Customer Care.

What are preventive drugs?

Preventive medications are generally prescribed for people who may be at risk for certain illness or condition, but are not yet showing symptoms. Preventive care generally does not include medications prescribed for treatment of an existing illness or condition.

ACA Preventive Drugs ― Members with plans compliant with the Affordable Care Act have access to a list of drugs mandated by the Affordable Care Act at no cost. These include but are not limited to certain prenatal supplements, contraceptives, fluoride for children and tobacco cessation aids. Some, but not all ACA drugs are listed in the formularies.

*High Deductible Health Plans (HDHP) or Health Savings Account (HSA) Plans ― Several Blue Cross of Idaho HSA policies offer coverage for an enhanced list of preventive medications, not subject to the deductible requirements of the plan. In addition, some employer groups may choose to purchase enhanced coverage for preventive drugs. The 2018 Preventive Drug List provides a list of medications covered under the preventive drug benefit . Members of HSA Qualified Health Plans are encouraged to check their applicable Qualified Health Plan Formulary for a complete listing of medications covered as preventive drugs.

Vaccines ― For policies that offer full coverage for preventive vaccines, members can get the following vaccines from participating network pharmacies with no copayment. (Check your summary of benefits and coverage to see the list of covered vaccines for your plan.)

  • Influenza
  • Pneumonia
  • Shingles

To maximize your benefits, we recommend that you get other preventive vaccines from an in-network primary care physician (PCP), as they have agreed to limit their charges to the amount that Blue Cross of Idaho will pay. Pharmacies are not obligated to limit their charges to the amount Blue Cross of Idaho will pay, which may result in higher costs to you. If you have other covered vaccines (not listed above) done at the pharmacy, you will need to pay the pharmacy and then submit a claim to Blue Cross of Idaho for reimbursement.

To locate a participating pharmacy, visit our Pharmacy Locator.