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Pharmacy Information

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HMO and POS Prescription Drug Program
Our prescription drug program for BlueChoice Healthcare Plan (HMO) and BlueChoice Option (POS) members is convenient and easy to use. Members simply present their member ID card at a participating pharmacy and pay either a standard copayment or discounted fee┬╣ for their medication. When prescriptions are filled at participating pharmacies, members are never required to file claim forms for reimbursement. 
A complete list of participating pharmacies can be found in our printed and on-line Provider Directory.  
Preferred Drug List  
BlueChoice Healthcare Plan and BlueChoice Option prescription drug coverage is based on the drugs listed in our Preferred Drug List. Our Preferred Drug List includes generic and selected brand-name drugs that are clinically safe and effective. Drugs are chosen based on clinical effectiveness, safety, ease of use and cost. 
Our Preferred Drug List balances cost while maintaining quality in two ways:  
It promotes the use of generic drugs when available and appropriate to treat a member’s medical condition.
It eliminates duplication of “like or similar” brand-name drugs within selected drug categories.
 
In many cases, different drugs in the same category can be used to treat the same medical conditions. Therefore, within a preferred drug list, it is not necessary to include all the equivalent brands. We have simply eliminated duplications and selected those that have been designated effective for inclusion in the drug list. 
HMO/POS participating physicians and network pharmacists receive a Drug List Guide that outlines the current drugs available on the drug list. This description includes helpful questions and answers about the prescription drug program and drug list, as well as a list of the most commonly prescribed covered drugs. 
Members pay a copayment when purchasing drugs currently on the applicable drug list from a participating network pharmacy or through home delivery. Standard in-network prescription benefits for BlueChoice Healthcare Plan and BlueChoice Option are not covered if a prescription is written by an out-of-network physician. 
Drug List Exception Process 
A physician may submit a request for a drug not available on the drug list to be evaluated for coverage. If the clinical information submitted by the physician meets the criteria established by the Pharmacy and Therapeutics Committee, a drug not included on the drug list will be approved for coverage. In this case, when drugs not included on the drug list are approved for coverage, members pay only the normal copayment when purchasing from a participating network pharmacy or through home delivery... 
Home Delivery 
Members of BlueChoice Healthcare Plan and BlueChoice Option can purchase maintenance prescription drugs that are included on their applicable drug list through home delivery. (Maintenance drugs are defined by First Data Bank*.) 
This is a convenient way for members to order up to a 90-day supply of maintenance medication for direct home delivery. 
*First Data Bank is one of the nation’s largest drug databases and provides the industry standard for defining maintenance and non-maintenance drugs. 
┬╣Discounted fee applies to out-of-network POS members. 
PPO Prescription Drug Program with Preferred Drug List
For fully insured and ASO (self-insured) PPO groups, we offer prescription drug programs with or without a Preferred Drug List: 
Our 3-tiered copayment prescription drug program is convenient and easy to use. Members simply present their member ID card at a participating pharmacy and pay one of three copayment benefit levels. When prescriptions are filled at participating pharmacies, members are never required to file claim forms for reimbursement. 
If drugs are purchased at a non-participating pharmacy, members will still be responsible for one of the three copayment benefit levels; however, members must file and submit a claim form for reimbursement. 
A complete list of participating pharmacies can be found in our printed and on-line Preferred Drug List
Standard Copayment Levels 
$10 copayment for a preferred generic drug
$20 copayment for a preferred brand-name drug
$40 copayment for a non-preferred drug
 
What is the Preferred Drug List?  
BlueChoice PPO’s prescription drug coverage is based on the drugs listed in our Preferred Drug List. Our Preferred Drug List includes generic and selected brand-name drugs that are clinically safe and effective. Drugs are chosen based on clinical effectiveness, safety, ease of use and cost. 
Our Preferred Drug List balances cost while maintaining quality in two ways: 
It promotes the use of generic drugs when available and appropriate to treat a member’s medical condition.
It eliminates duplication of “like or similar” brand-name drugs within selected drug categories.
 
In many cases, different drugs in the same category can be used to treat the same medical conditions. Therefore, within a Preferred Drug List it is not necessary to include all the equivalent brands. We have simply eliminated duplications and selected those that have been designated effective for inclusion in the drug list. 
Under the three-tier benefit, all medications are covered at the appropriate copayment level described above. 
PPO Prescription Programs without a Preferred Drug List
ASO groups that do not want a Preferred Drug List may select between two different prescription drug programs: Pay the Difference and Deductible and Coinsurance. 
Pay the Difference Program without Preferred Drug List 
This plan design is convenient, easy to use and encourages utilization of generic – rather than brand-name – drugs. Members simply present their member ID card at a participating pharmacy and pay a copayment for all generic drugs. If the member receives a brand-name drug, he/she will be responsible for paying the copayment plus the difference between the brand-name and the generic drug. 
When prescriptions are filled at participating pharmacies, members are never required to file claims forms for reimbursement. A complete list of participating pharmacies can be found in our printed and on-line Provider Directory
Deductible and Coinsurance Program without Preferred Drug List 
Under this program, members pay for prescriptions at the pharmacy but are reimbursed, less their deductible and coinsurance. Members do not need to file claim forms for prescriptions that are filled at participating pharmacies. If a member uses a non-network pharmacy, they may need to file a claim form for reimbursement; his/her out-of-pocket costs may be higher since he/she will only be reimbursed at the in-network rate..Under this program, prescriptions do not need to be filled according to our Preferred Drug List.  
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.