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Coverage Requirements and Limitations
To ensure that prescription drugs are used safely and cost-effectively, some drugs are included in our Responsible RX programs. These program requirements include:
- Your doctor may need to submit a Prior Authorization request before the drug will be covered. Without a Prior Authorization approval, your drug may not be covered and you may pay the full cost.
- There may be another drug that is clinically effective that must be tried first. If you’ve already tried the other drug(s), your doctor can submit medical records for consideration.
- There may be a quantity limit on the amount filled each time. If you require more than the allowed limit, your doctor can submit a request for consideration.
Login for quick answers about your specific drug coverage. View your Medication Guide or use the Drug Comparison Tool.
Drug Tiers and Your Cost Share
In general, choosing Tier 1- generic drugs, using PrimeMail (if available) and going to an in-network pharmacy saves you the most money.
Your cost share is based on aand . The lower the tier, the lower your cost share will be. Some plans include 2 tiers while others include 3 to 7 tiers. Below you’ll find an example of a 4-Tier plan and how it works. For the drug tiers and cost shares that apply to your plan, login to your member account.
- Tier 1 — Generic Drugs
- Tier 2 — Preferred Brand Drugs
- Tier 3 — Non-Preferred Brand Drugs; these drugs may have generic or brand alternatives in Tier 1 or Tier 2 that can save you money.
- Tier 4 — Specialty drugs, including self-administered, injectable medications, and high-technology drugs.
Tip: Use PrimeMail home delivery services to get a 90-day supply of medication. Check your plan benefits for mail-order cost savings.
These examples assume the drug is covered by your plan and you use a pharmacy in your plan’s network.
Let's say you take cholesterol medication and your cost share amounts are:
- Tier 1 — Generic = $10 copay
- Tier 2 — Preferred Brand = $25 copay
- Tier 3 — Non-Preferred Brand = $50 copay after deductible of $500
- Tier 4 — $150 copay after deductible
Your cost share is based on the tier level and drug category:
Tier 1 — Niacin Extended Release (500 MG)
Niacin Extended Release is a generic medication. Because it's a Tier 1 drug, you would pay a $25 copay.
Tier 2 — Crestor (40 MG)
Crestor is a Preferred Brand drug. You may be required to try a generic drug before your plan will cover the brand alternative. Because it's a Tier 2 drug, you would pay a $25 copay.
Tier 3 — Advicor Extended Release (500 MG)
Niaspan Extended Release is a Non-Preferred Brand drug. You may be required to try a generic drug and get a prior approval before your plan will cover a Non-Preferred Brand. Because this tier includes a deductible, you would pay full cost of your medication until you reach your deductible, then you would pay a $150 copay for each prescription.
PrimeMail Home Delivery
If your plan includes mail order services, you may be able to get a 90-day supply of medication at a lower cost. Some plans include generic medication to manage chronic conditions at no cost when you order by mail. Check your plan benefits and don’t forget to use the Drug Comparison tool.
Note: If special prices are available at select pharmacies, the Drug Comparison tool at FloridaBlue.com will flag it. Log in now to see the Drug Comparison tool in action!
Save Trips to the Pharmacy: Sync Your Refills
Filling more than one prescription each month can mean several trips to the pharmacy. You may be able to sync your prescriptions and pick them up at the same time, even if the entire supply hasn’t been used yet. You can do this in person at your pharmacy or through mail order. Here’s how:
1. Refill Limitations let you refill your prescription before you run out. You don’t need any sort of special permission at the pharmacy or through mail order.Details
- You can refill at a pharmacy after 75% or more of the 30- or 90-day supply has been used. (That’s 23 days of a 30-day supply or 68 days of a 90-day supply.)
- When using mail order, you can get a refill after 60% (54 days) or more of the 90-day supply has been used.
- Exception: You can refill migraine medications (called triptans) in person after 100% of the total days (30 days of a 30-day supply) and by mail after 85% of the total days (25 days of a 30-day supply).
2. Early Refills lets you fill prescriptions for special situations, like if you’re going on a long vacation or if your drug is lost or stolen. To refill at a pharmacy or mail order, either the pharmacy staff or the member must call Prime Therapeutics for approval. The number is 800-821-4795.Details
- You can get a vacation supply of up to 90 days at your pharmacy.
- You’ll pay one copay for every month the supply is filled.
- When using mail order, you can get a refill of up to 180 days.
- You’ll pay one mail-order copay for every 90-day supply.
- You can get enough medication to last up to the last day of your plan’s coverage.
- Exception: Specialty drugs do not apply.
The following can't be partially filled using the sync program:
- Over-the-counter medications
- Controlled substances
- Prescriptions dispensed in an unbreakable or multi-dose package
Fine Print on Refill Time Frames and Controlled Substances
- Prescriptions can be filled or refilled within one year from the date they are written.
- Prescriptions for a controlled Schedule II can’t be refilled.
- Prescriptions for a controlled Schedule III, IV or V can’t be filled or refilled more than five times within six months after the date they were written.
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