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Pharmacy Information

PW_A091030

Prescription Drug Plan

NEW Prior Authorization Process

Member and Physician Engagement

Drug List Management

Additional Resources for our Providers

Prescription Drug Plan

We look at our members holistically and offer coordinated medical and pharmacy benefits to help close gaps in care and improve overall heath. We may help improve your patient’s health outcomes when we combine our medical, pharmacy and lab data – but we go beyond the data to help ensure coordination of our people, programs and knowledge.  
With our drug lists and our gaps-in-care messaging, we improve member health. When we develop our drug lists, we see how drugs work in real life for our members. We use our medical and pharmacy data and analyze claims to make sure the medications really work.  
But that’s just the beginning.  
Improving the health of our members

We encourage medications that improve patient health, and we see how drugs work in real life for our members, helping them make good health care choices.

Reducing total health care costs

Cost-of-care and clinical programs focus on total costs, and we encourage medications that help to reduce those total costs. Both medical and pharmacy costs are our responsibility.

Ensuring coordination of care

Medical and pharmacy strategies complement each other; they’re based on the same goals. Policies are aligned. We engage members and you, their doctors.

 
Simplifying the member experience

Our medical and pharmacy experts work collaboratively. Members have one vendor, one contact, and one ID card. Clients have one vendor, one contact, one contract, one eligibility feed, and one invoice.

Prior Authorization Process

Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered. This approval process is called Prior Authorization
To submit Electronic Prior Authorization (ePA) requests, log in through this site. Creating an account is free.

Contact Information: While ePA helps streamline the prior authorization process, if you must initiate a new PA request by fax or phone, please note the following contact numbers:
 

Phone:

Commercial (Off Exchange): 833-293-0659

On Exchange: 833-293-0660

 

Fax:

Commercial (Off Exchange): 844-512-9002

On Exchange: 844-512-9003

For pharmacy benefit questions members should call the Member Service number on their ID card.  

Member and Physician Engagement

We drive compliance to improve health and reduce costs. Gaps-in-care messaging for our clinical and cost-of-care programs is included in one communication. Members don’t receive multiple letters focused on individual clinical and cost-of-care programs. And to help ensure coordination of care and compliance, physicians also receive a consolidated communication with similar messages. By using targeted, concise communication, we help members make good health care choices and improve health outcomes.  
Medication Review

Once we identify a gap in care, the member receives a personalized Medication Review, which contains pharmacy messaging for our clinical and cost-of-care programs in one consolidated, health plan-branded, monthly member communication.

 
MyHealth Note

When clients have both our medical and pharmacy benefits; we can access members’ combined medical, pharmacy and lab data, plus member eligibility and benefit information, in order to create a holistic picture. This allows us to send generic and therapeutic equivalent messages with member-specific cost savings.

 
Controlled Substance Utilization Management

Our Patient Highlights communication is focused on controlled substance care opportunities, including the identification of members receiving multiple controlled substance medications, high dose opioids or opioids from multiple providers and filled at multiple pharmacies, or combinations of controlled substances that may indicate risk.

 

Drug List Management

Drug Lists

We are leading the health care industry in the way we choose covered drugs, analyzing the strongest clinical drug studies – and, we use our member data, including pharmacy, medical and lab data, to see how drugs are really working for our members. We believe the right drugs to cover are the ones that do the best job for members, and reduce the total cost of care. Review our Commercial drug lists.

 
Pharmacy & Therapeutics (P & T) Committee

A group of doctors and pharmacists – who are not our employees – lead the selection of drugs for our drug lists. This group performs regular clinical reviews, rates drugs based on how they work in real life, evaluates drug costs to make sure they are affordable, and chooses drugs that are safe, work well and offer the best value.

 
Therapeutic Equivalents

We look at claims data to find opportunities for our members to save money by switching them to lower-cost, therapeutically equivalent drugs. We send members personalized messages about medications that may reduce their costs – and include specific cost savings.

 
Generic Drug Strategy

We take a comprehensive approach to encourage generics and help keep our members healthy and reduce costs.

 
Maintenance Medication Prescriptions

We offer home delivery, and the Retail 90 and Smart 90 pharmacy networks as options for members to fill up to a 90-day supply of their maintenance medications. Members can download and print the physician fax form from the website of our pharmacy benefits manager, Express Scripts, with the new prescription for a 90-day supply.

When you write the new prescription, you can fax or efax the form and prescription to the phone number on the form. We'll take it from there.

 
Pharmacy Home Program

This program identifies members who may be over-utilizing providers, medications, and pharmacies to obtain controlled substances. After a warning period to correct behavior, members become restricted to one pharmacy, designated as the home pharmacy. A partnership with our providers, will enhance this program’s ability to reduce the risk of opioid misuse and enable earlier identification of members facing substance use related conditions.

 
What if a medication is not on the Drug List?

Our drug lists allows members and their doctor to choose from a wide variety of prescription drugs. Members should talk with their doctor about prescribing a drug that is on the drug list. If a medication is selected that is not on the drug list, the member will be responsible for the full cost of the drug.

Additional Resources for our Providers

Specialty Pharmacy Network Lists

Members taking specialty drugs, may need to get your prescription filled at an in-network specialty pharmacy in order for their drug to be covered under their pharmacy or medical benefit. See what specialty pharmacies are considered in-network

 
Hemophilia Drug Therapy Network List

CVS Specialty and Hemophilia Treatment Centers on the list are considered in-network and will lower costs for members receiving Factor treatment under the medical benefit.

Provider network for hemophilia drug therapy

 
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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.