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Remember that drug prices shown are general retail prices and do not take into account cost sharing amounts (copay, coinsurance, or deductibles) that may exist for specific plans. If you are a Blue Cross member sign in to myBlueCross for more specific pricing information. Also, you can refer to the specific benefit plan details to see how drugs will be covered under your plan. Blue Cross and Blue Shield of Alabama does not prescribe medication nor do we attempt to alter what your doctor has prescribed. We offer this information on prescription drugs to ensure that our members receive quality, cost-effective medications. This database provides information based on Generic, Preferred and Other Brand Drug copay/coinsurance structures. Based on this information, you may want to discuss with your doctor the options of alternative medications that will lower your copayment and/or the amount you are required to pay out of pocket. Tier 4 and 5 specialty drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Drug Pharmacy Program. Tier 1 (Generics): $7.50 copay for up to a 30-day supply; $22.50 copay for a 31 to 90-day supplyTier 2 (Preferred brand): 30% of our allowance Tier 3 (Non-preferred brand): 50% of our allowance Tier 4 (Preferred specialty): 30% of our allowance Tier 5 (Non-preferred specialty): 30% of our allowance Tier 4 and 5 specialty drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Drug Pharmacy Program. Mail Service Pharmacy Not a benefit Available to members with Medicare Part B primary only. Visit the Medicare page for more information. Tier 1 (Generics): $15 copayTier 2 (Preferred brand): $90 copay Tier 3 (Non-preferred brand): $125 copay Covers a 22 to 90-day supply. Nothing for the first 4 prescription fills or refills when you switch from certain brand name drugs to specific generic drugs. Specialty PharmacyTier 2 (Preferred generic specialty, and Preferred brand specialty): 40% of our allowance ($350 maximum) Most patients with Blue Cross NC health insurance also have a medication plan to cover the medications they get at their pharmacy. Each medication plan comes with a list (or formulary) that shows you what medications are covered. Are your patient's prescription medications covered?1) Look for the "Rx" on their member ID card. It means they have medication coverage. 2) Look for a capital letter or a capital letter/number combination after the 'Rx' on your patient's card. The letter will tell you which drug list, or formulary, your patient's plan uses. The number gives information about the pharmacies in your patient's network. Enhanced Drug List Essential Drug List Net Results Drug List 
How to Find Your Patient's Approved Medication List or Formulary1) Return to the Providers homepage
2) On the Find a Doctor, Drug or Facility page
You'll go to Prime Therapeutics, our pharmacy benefit manager's website. Your patient's medication list, or formulary, search should look like this: 3) Type a medication name in the blue search box, select the formulation and strength you are prescribing and click Submit.
Medications that Need Prior AuthorizationSome medications need additional information, in writing, from you before Blue Cross NC can decide if they will be covered. Our drug search tool shows the restricted medications our members use most, the requirements for approval, and the details you must send us to get them approved. PROVIDERS: Skip the Fax – Submit Forms OnlineDid you know you can quickly submit forms through Blue e? Just log in, complete the form and send it to us electronically. No printing or faxing required! Blue e Login Enter a drug name in the search box to see if it needs approval before it's covered by a patient's plan. Search by drug name: Or click the first letter of your drug to view lists: To find a drug, use the search above or select a letter from the list above. Brand Drug Name: {{header}}
Words that you may see in the drug searchPrior AuthorizationProviders must explain in writing why patients need a certain medication before Blue Cross NC can decide if it will be covered. Quantity LimitsTo encourage the proper use of prescription medications, Blue Cross NC may restrict the amount of medicine an insurance plan covers. This may mean taking fewer pills each day without changing the total strength of the medication. Step TherapyBlue Cross NC requires that patients first try a medication or device that is not restricted before a restricted medication will be approved. Patients may be covered for a restricted medication if providers tell Blue Cross NC in writing that: The patient has already used the non-restricted medication and it wasn't effective in treating the condition; or The provider thinks the non-restricted medication is likely to be harmful to the patient's health or not effective in treating their condition. Non-formularyA non-formulary medication is one that isn't on a patient's Blue Cross NC medication list. Not all medication lists or formularies have non-formulary medications. Providers must confirm that a patient has tried the medication(s) on their list first, and that they were ineffective or harmful. Also, any medication-specific clinical criteria must be met before approval (available in the Drug Search). Specialty DrugsMay be used to treat a complex or rare condition, and are generally:
Specialty drugs are limited to a 30-day supply and patients must get them from an in-network specialty pharmacy, so their benefits will apply to the prescription. In-network pharmacy options vary based on the patient's plan benefits.
Important: If your patient has changed health plans, you may need to tell us that your patient has met the rules for their new plan. For Patients with an Essential Medication List (Formulary): If your patient meets the Criteria for Approval of Restricted Products (pdf), and their list says that Prior Review (Prior Authorization) or Step Therapy is required for a medication, but the medication isn't in the Drug Search, please send a request to Blue Cross NC using this General Authorization Fax Form (pdf). Requesting Medications Not on Your Patient's Approved Medication List (Formulary)For fastest processing, please submit requests online using CoverMyMedsTM. If all details are submitted online and the request is approved, the member may be able to pick up their prescriptions at the pharmacy in less than 2 hours. Other processing methods include:
Once we have all required information, we'll make a decision within 3 business days and notify you. Requests are processed within 72 hours, unless urgent. Urgent requests are handled within 24 hours. An urgent request is when you believe a delay would seriously jeopardize the life or health of the patient, the patient's ability to regain maximum function, or would subject the patient to severe pain that cannot be adequately managed without the care or treatment requested. Authorization for Essential and Net ResultsIf you want your patient to take a medication that isn't on the Essential or Net Results medication list, here's what to do:
Cost Information for Essential and Net ResultsFor members on the Essential Medication List (formulary), if request for a non-formulary medication is approved, these cost levels or "tiers" will apply: Essential 5 Tier = Tier 5 For members on the Net Results Medication List (formulary), if the request for a non-formulary medication is approved, these cost levels or "tiers" will apply: Non-specialty medication = Tier 4 Medications with Limited or No Plan CoverageSome medications may not be covered by the patient's plan or may have a limited amount the patient can receive. The Table of Drugs with Limited or No Coverage shows a sample listing. Not all limited medications are listed. For self-funded and ASO patients, you may need to call Blue Cross NC Customer Service for medication limits that may apply. If you are unsure if your patient's group is an underwritten or self-funded/ASO group, call the customer service number listed on the back of your patient's member ID card. Table of Drugs with Limited or No CoverageDrug TypeDrug LimitsInfertility Drugs For groups that, in 2013, had a $5000 lifetime maximum and were able to carry this over due to updates to the Affordable Care Act, this benefit will remain available. Otherwise, the benefit is as follows (call Customer Service to confirm):
*Requires prior authorization before being covered Sexual Dysfunction Drugs Related to Organic Disease (e.g., Cialis, Viagra, Caverject)Underwritten and Individual / Family plans:Tadalafil (Cialis) 2.5mg or 5mg: 30 tablets per 30 days 4 tablets or units per 30 daysSexual Dysfunction Drugs Unrelated to Organic DiseaseAll: Not coveredPrenatal VitaminsLimited to members that are planning pregnancy, currently pregnant, or breastfeeding. If you believe you should qualify for an exception, please have your provider complete this form, and submit to Blue Cross NC for review. View the prenatal vitamin criteria for approval. In addition to the above benefit limitation, some prenatal vitamins are excluded from coverage entirely. These include, but are not limited to:
All: Not covered; please see the non-FDA approved medication and product list for specific medications that aren't covered Initial fill of immediate-release opioidAll: Limited to maximum of 7 days for initial fill. If this is not the first fill, but Blue Cross NC does not have the patient's claims history, use this IR Opioid QL Criteria (pdf) and IR Opioid QL Fax Form (pdf).Prescription medications with over-the-counter (OTC) alternativesPlease see member guide for coverage.Not covered as a standard benefit. Please see list for specific drugs that are not covered.Medications used solely for weight lossPlease see member guide for coverage. Not covered as a standard benefit. Please see list for specific drugs that are not covered.High Dollar VerificationSingle claims over $10,000 require prior authorization (excluding antivirals, anti-infectives, anti-convulsants, insulin, specialty medications, and medications already subject to Prior Authorization or Step Therapy requirements). Criteria information can be found here, and fax submission information can be found by clicking here. Brand-Name Drugs vs. GenericsDon't let your patient over pay! They could be charged more if you prescribe a brand-name medication instead of a generic. If there's a medical reason the patient needs a brand-name medication, please: Does BC Blue Cross cover Ozempic?Today BC Pharmacare announced coverage of semaglutide (“Ozempic”), a once-a-week shot, for individuals living with Type 2 diabetes on oral medication alone (metformin & glyburide) or on insulin plus metformin.
Will insurance cover Ozempic for weight loss?Insurance won't cover Ozempic, Rybelsus and Wegovy for Weight Loss? Since the medication semaglutide was first developed for the treatment of type 2 Diabetes, many insurances still will not cover the prescription, brand name or generic, for weight loss.
Is there a generic drug for Ozempic?Ozempic (semaglutide) is used to improve blood sugar control in adults with type 2 diabetes. There are currently no generic alternatives for Ozempic.
What tier level is Ozempic?What drug tier is Ozempic typically on? Medicare prescription drug plans typically list Ozempic on Tier 3 of their formulary. Generally, the higher the tier, the more you have to pay for the medication.
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Is ozempic covered by blue cross blue shield
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