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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:

  • Prior Authorization:1 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.
  • Step Therapy:2 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.
  • Quantity Limits:3 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

Follow these 3 simple recommendations to save you the most money on your prescription drugs.

  1. Use Tier 1 generics.
  2. Use an in-network pharmacy like Walgreens or Publix. Check your benefits package with your employer, or log in to your online account and search for the list of pharmacies in your network.
  3. Use AllianceRx Walgreens Prime (mail-order) home delivery service for maintenance medications.

Your cost share is based on a tier level4 and drug category5. 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. This example doesn’t represent the drug tier structure for all Florida Blue plans. For the drug tiers and cost shares that apply to your plan, log in to your online account. You can find other resources for drug tier information and cost information in your plan’s medication guide or by using the Drug Comparison Tool.

Example

  • Tier 1 — Generic Drugs with $10 copay
  • Tier 2 — Preferred Brand Drugs with $25 copay
  • Tier 3 — Non-Preferred Brand Drugs with $50 copay after deductible of $500 is met. Ask your doctor about generic or brand alternatives in Tier 1 or Tier 2, which can save you money.
  • Tier 4 — Specialty drugs with $150 copay after deductible of $500 is met. These drugs include self-administered, injectable medications and doctor-administered drugs.

Express Scripts Pharmacy® Home Delivery

If your plan includes home delivery 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.

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 home delivery. 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 home delivery.

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 home delivery, 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 home delivery, 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 home delivery, you can get a refill of up to 180 days.
    • You’ll pay one home delivery 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.

Exceptions

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.

1A prior authorization is an approval from Florida Blue that is required before certain services will be covered by your health plan. Your doctor will need to submit an authorization request that is approved prior to these services to ensure you have coverage. Exceptions may apply for medical emergencies.

2Certain drugs are not covered unless you try another FDA approved drug first. There may be a lower cost drug that is clinically and cost effective to treat your condition. If an alternate drug is not recommended for you or you had other insurance when you tried the alternate drug, simply ask your doctor to submit an authorization form to request that the drug be covered.

3Some drugs have a maximum quantity that is covered for a given time period. For example, if your doctor prescribes a medication that has a 30-day limit of 9 tablets, your plan covers 9 tablets that month. These safety limits are based on the drug manufacturer’s and Food and Drug Administration’s dosing guidelines.

4Prescription drugs are grouped by Tier. The lower the tier, the lower your cost share.

5This refers to a group of drugs, such as generic, preferred brand, non-preferred brand or therapeutic alternative.

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