Your prescription drug benefits
Tips for home delivery
When ordering a day supply or refills of a prescription drug through home delivery:
- Be sure your doctor indicates day supply and the number of refills you need on your written prescription.
- Note that 60 percent of the previous supply must be used before a refill is sent.
- Allow up to 14 days for delivery and have at least two weeks of medication on hand when ordering any refills.
You can set up auto-refills so you can conveniently continue receiving your medications at home until you have either used all of your refills or your prescription expires. Note that you will need to set up auto-refills each time your doctor writes a new prescription for you, even if it is for a drug you have ordered before.
Orders totaling $ or less will be charged to the payment method in your account (a credit or debit card, for example). If your order is over $, you must authorize payment before your order will be shipped. AllianceRx Walgreens Prime (the home delivery pharmacy), will attempt to call you three times for payment authorization. If they are unable to reach you or you do not return their call after the three attempts, your order will be canceled.
Which drugs does my plan cover?
Your formulary is a list of drugs covered by your health plan. Capital Blue Cross manages the formulary by including generic and brand-name prescription drugs that focus on your safety and help you save money. Every drug listed on the formulary has been approved by the U.S. Food and Drug Administration (FDA), which means they have been carefully tested and meet strict safety standards.
Generic drugs are typically the most affordable and offer a lower cost share than brand-name drugs. The active ingredient in a generic drug is chemically identical to the active ingredient in the brand-name version. To help lower your out-of-pocket costs, choose generic drugs whenever possible. Your formulary may classify generic drugs into two categories: generic preferred and generic nonpreferred. The difference between the two is their cost—generic preferred drugs typically cost less than generic nonpreferred drugs. Note, however, that generic nonpreferred drugs usually cost less than brand-name drugs.3
Brand-name drugs are marketed and sold under a specific trade name and are protected by a patent. Your formulary may classify brand drugs into two categories: preferred and nonpreferred. Brand preferred drugs usually cost more than generics but normally cost less that other brand drugs that treat the same condition. Brand nonpreferred drugs usually have the highest cost share and receive their label because they have not been found to be more cost effective than available generic, over-the-counter, or preferred brand drugs.
This process encourages medically appropriate and cost-effective use of certain drugs. You can easily find these drugs on your formulary.
To help prevent possible delays in filling prescriptions that require prior authorization, you or your doctor should request prior authorization before your prescriptions are filled. Your benefits will not cover prescription drugs that require prior authorization until the authorization is secured.
Your in-network doctor will request prior authorization for you. You can also start a prior authorization request by calling the Member Services number on your member ID card or by logging in to your secure account. You will need:
- Your name (as it appears on your member ID card)
- Your member number
- Your date of birth
- Name of the drug
- Name of the doctor who prescribed the drug
- Prescribing doctor’s phone number
- Prescribing doctor’s fax number (if available)
If your authorization is not approved, you can still get your prescription; however, you will be responsible for the entire cost of the drug. You may appeal the decision or you may ask your doctor to prescribe another drug that is covered by your benefits. Note that if your prescribing doctor is not in Capital Blue Cross’ network, you are responsible for requesting prior authorization.
Enhanced Prior Authorization4 (Step Therapy)
Your plan includes a process called enhanced prior authorization for certain prescription drugs, which means you may be asked to try a different drug first. Your doctor or pharmacist can call Capital Blue Cross at the phone number listed on your member ID card to start enhanced prior authorization. You can also start the process by calling the Member Services number on your member ID card or through your secure account.
Drug Quantity Management Program
Your plan also includes quantity limits for certain prescription drugs to support safety. These drugs will be noted on your formulary. If your prescription is written for more than the allowed quantity, your pharmacy will only fill up to the allowed amount. Your doctor can request an exception to quantity limits by calling the number on your Capital Blue Cross member ID card.
Generic Substitution Program
Your benefits may include a mandatory or restrictive generic substitution program to help you save money and control drug costs. Under the mandatory program, your pharmacy may replace a brand-name drug with a generic one. If you request the brand-name one, you will be charged the brand-name cost share plus the cost difference between the generic and brand-name medication.
Under the restrictive program, your doctor can write Brand Medically Necessary on your prescription. In this case, you will only be charged the brand-name cost share. However, if you request a brand-name drug when a generic is available, you will be charged the brand-name cost share plus the cost difference between the generic and brand-name medication. Check your plan highlight sheet or Certificate of Coverage to see if either program applies to your plan.
Specialty Drugs (self-administered)
AllianceRx Walgreens Prime serves as your plan’s specialty drug pharmacy. If you need a specialty drug to manage your unique health condition, a patient care coordinator from AllianceRx Walgreens Prime will work with a team of pharmacists, nurses, your doctor, and Capital Blue Cross to give you personalized care that helps best manage your needs. Your services include:
- Help getting prior authorization and refills
- The convenience of having your drugs delivered directly to your home at no additional cost
- Free supplies, such as needles, syringes, and disposal containers
- Training and educational resources to help ensure you know how to take your medication
- Care management programs that can help you get the best results from our prescribed drug therapy
Your Certificate of Coverage includes specific terms, conditions, exclusions, and limitations about your specialty drug benefits.
For more information about specialty drugs, call AllianceRx Walgreens Prime at
As a Capital Blue Cross member, you have access to thousands of retail pharmacies across the country, including many well-known chains (such as CVS, Rite Aid, Target, and Wal-Mart), grocery stores, and independent pharmacies. To help make sure you pay the lowest amount for your prescription drugs, use a pharmacy in your plan’s network. You can find in-network pharmacies by logging in to your secure account calling the Member Services number on your member ID card.
If your plan includes this program, you must get your maintenance drugs in day supplies. Remember to ask your doctor to write a day prescription. You can fill your day prescriptions for maintenance drugs through home delivery or by picking them up at pharmacies that are part of the Extended Supply Network.
Some plans allow an initial day fill and a day refill for maintenance drugs before 90DayMyWay requires members to get day fills. Check your Certificate of Coverage for details. Drug quantity level limits apply to all applicable generic equivalents of the brand-name products. Applicable home delivery quantity levels are two to three times the retail quantity level limits, depending on the prescription drug benefit design chosen by the member or employer group.
Extended Supply Network
This network includes pharmacies that are allowed to dispense prescriptions drugs in amounts up to 90 days. Most of the popular retail chain and grocery store pharmacies are part of the Extended Supply Network. You can find which pharmacies are part of the Extended Supply Network by logging in to your secure member account or calling the Member Services number on your member ID card.
Log in to your secure account to manage your prescription drug benefits. See which drugs are covered by your plan (your formulary), find pharmacies, and learn more about your plan’s prescription drug programs in this one-stop shop. Also, your Member Services team is available 24 hours a day, seven days a week to answer your pharmacy benefit questions. You can call them at the number on your member ID card.
Savings and convenience from your plan’s pharmacy network
Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare contract. Blue MedicareRx Value Plus (PDP) and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to service residents of Connecticut, Massachusetts, Rhode Island, and Vermont.
Coverage is available to residents of the service area or members of an employer or union group and separately issued by one of the following plans: Anthem Blue Cross® and Blue Shield® of Connecticut, Blue Cross Blue Shield of Massachusetts, Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.
S_ Page Last Updated 10/01/
Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.
Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are Independent Licensees of the Blue Cross and Blue Shield Association®, SM, TM Registered and Service Marks and Trademarks are property of their respective owners. © All Rights Reserved.
Blue Cross Medicare Advantage has contracts with pharmacies nationwide that equal or exceed the Centers for Medicare & Medicaid Services requirements for pharmacy access. To get benefits, you must use network pharmacies or our home delivery pharmacy service, except in emergencies.
Search the Pharmacy Finder tool to find the most up-to-date network of pharmacies.
Preferred Network Pharmacies
The Blue Cross Medicare Advantage pharmacy network has both preferred and standard pharmacies to choose from when you fill your prescription drugs. You may choose either type, but you will usually save money by paying a lower copay or coinsurance when you use a preferred pharmacy. Preferred network pharmacies include Albertsons, Amigos, Brookshire's, HEB, Kroger, Market Street, Randalls, Tom Thumb, United Supermarkets, Walgreens, Walmart and other independent pharmacies. Check the pharmacy directory for a full list of preferred pharmacies.
In addition to network pharmacies, you can use AllianceRx Walgreens Prime or Express Scripts® Pharmacy. These are our home delivery pharmacy services that offer:
- Three ways to order refills: online, by phone or through the mail.
- Up to a day supply of medications at one time.
- Notifications when your order is received and when your prescriptions are sent (by email or over the phone, whichever you prefer).
You can contact AllianceRx Walgreens Prime at (TTY ). Or, you can contact Express Scripts® Pharmacy at (TTY ).
Prime Therapeutics LLC has an ownership interest in AllianceRx Walgreens Prime, a central specialty pharmacy and home delivery pharmacy. Prime Therapeutics LLC, provides pharmacy benefit management services for Blue Cross and Blue Shield of Texas and is owned by 18 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans.
Express Scripts® Pharmacy is a pharmacy that is contracted to provide mail pharmacy services to members of Blue Cross and Blue Shield of Texas. Express Scripts® Pharmacy is a trademark of Express Scripts Strategic Development, Inc.
Covered drugs are available at out-of-network pharmacies in emergencies or unusual circumstances and for non-routine access to covered Part D drugs (illness while traveling outside the plan’s service area where there is no network pharmacy, for example). For more information on these special circumstances for out-of-network coverage and/or what pharmacies may be available to you, please contact us.
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