Drug formulary FAQs
What is a drug formulary?
A formulary is a list of preferred generic and brand-name medications approved by the Food and Drug Administration (FDA) that are covered under your Blue Shield Outpatient Prescription Drug benefit. You can check your Evidence of Coverage (EOC) or Certificate of Insurance (COI), or call the Customer Service number on your Blue Shield member ID card, to determine whether the formulary applies to your plan. The fact that a drug is listed in the formulary does not guarantee it will be prescribed by your physician.
How are Blue Shield drug formularies developed?
The Blue Shield Pharmacy and Therapeutics (P&T) Committee develops Blue Shield drug formularies. The P&T Committee reviews medical literature concerning safety, effectiveness, and current use in therapy to determine which drugs should be included on our formularies. The medical information reviewed is from a variety of nationally recognized sources such as Medline, other databases, pharmaceutical manufacturers, medical professional associations, and peer-reviewed journals. The P&T Committee reviews and updates the formularies regularly to ensure coverage of drugs that are cost-effective and safe. Through the use of the drug formulary associated with your plan, we can help maximize treatment quality while keeping your prescription drug costs lower.
P&T Committee-approved additions or removal of drugs from the Blue Shield formularies are promptly listed on the online drug formulary page. For a copy of the drug formulary that applies to your plan and the latest formulary updates, please check the Drug formularies page and the Formulary change announcements.
What is a brand-name drug?
A brand-name drug is a medication that the FDA has approved for sale and marketing in the U.S., and has patent protection that limits which manufacturer(s) can make and sell the medication. Generic versions of brand drugs cannot be made or sold until the patent has expired. Once the patent has expired, generic versions of the medication can be sold alongside the brand version.
What is a generic drug?
A generic drug has the same active ingredient and dosage form (e.g. tablet or capsule), and works in exactly the same way as its brand-name counterpart. When the patent on a brand-name drug expires, other drug manufacturers can apply to the FDA to make a generic version of the drug. The FDA approves generic drugs when manufacturers have proven that the generic version is as equally safe and effective as the brand-name counterpart.
Generic drugs usually cost less than the brand-name equivalent. Therefore, using generic drugs instead of a brand-name drug is one of the easiest ways to reduce your prescription costs. Most Blue Shield health plans provide a lower copayment for generic drugs, compared with brand-name drugs.
What are specialty drugs?
Specialty drugs are drugs used to treat complex or chronic conditions and usually require close monitoring. Specialty drugs may be self-administered in the home by injection (under the skin or into a muscle), by inhalation, by mouth, or on the skin. These drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability.
Specialty drugs are available from a Blue Shield specialty pharmacy, and may require prior authorization from Blue Shield for medical necessity . If coverage is approved, you can only obtain the drugthrough one of our specialty pharmacies. Select drugs may not be available for distribution through the Network Specialty Pharmacy, in which case you may obtained them through a non-network specialty pharmacy.
You can download the list of specialty drugs that corresponds with your drug formulary.
What is prior authorization?
Drug prior authorization is a process to obtain pre-approval for coverage of a prescription medication. This is to ensure that you receive medications that are safe and effective for your condition. Your doctor may provide information for a prior authorization review by calling or faxing a form to Blue Shield Pharmacy Services. Your doctor will be notified whether or not your prescription is approved for coverage.
The Blue Shield P&T Committee determines prior authorization coverage requirements to ensure that medications are prescribed for medically necessary reasons, used safely as recommended by the FDA and in medical studies, and used when formulary alternatives have been considered first. Drugs require prior authorization when:
- Other drugs are recommended as first-choice treatment, based on nationally recognized clinical guidelines, the FDA, or the medical literature.
- There is no significant clinical advantage compared with other formulary drugs that treat the same condition, based on clinical study results.
- The drug should be reserved for rare or uncommon conditions.
- The drug has a high potential for toxicity, abuse, or misuse.
- The dose, prescription quantity, or duration of use exceeds FDA recommendations.
Finally, prior authorization helps keep prescription costs affordable by suggesting use of formulary drugs first.
What is step therapy?
Step therapy is the practice of beginning drug therapy for a medical condition with drugs considered first-line for safety and cost-effectiveness, then progressing to other drugs that may have more side effects or risks or that are more costly. The P&T Committee may determine that coverage of selected drugs requires step therapy with first-line drugs before covering the prescribed medication. Step therapy requirements are based on how the FDA recommends that a drug should be used, nationally recognized treatment guidelines, medical studies, information from the drug manufacturer, and the relative cost of treatment for a condition. Other common terms used for step therapy are “prerequisite therapy,” “prior therapy,” or “step therapy protocol.”
If step therapy coverage requirements are not met for a prescription and your doctor feels that the medication is medically necessary for you, your doctor may request an exception to the coverage requirements by requesting a prior authorization review.
How do I use the Blue Shield Drug formulary?
To minimize your out-of-pocket expenses, we recommend that you and your doctor consult the Blue Shield Drug formulary related to your plan before writing or filling prescriptions. It may be helpful to bring your Blue Shield drug formulary with you when you visit your doctor, so that you and your doctor can make decisions about alternative medications, if necessary. Ask your doctor to prescribe a generic drug when you need to be treated with medication. If a generic drug is not available, or if your doctor prescribes a brand-name drug that is not listed in the formulary, consider asking your doctor whether a formulary brand-name drug may be just as effective and right for you.
Check the drug formularies page for the most current information about which drugs are on your formulary.
How can I obtain a copy of my plan's Blue Shield drug formulary?
You can view the most up-to-date drug formularies online. Please check the drug formularies page for the most current information about which drugs are on your plan's formulary. You can also obtain a printed copy by calling Customer Service. The number is listed on your Blue Shield ID card.
You can also obtain a printed copy by calling the Customer Service number listed on your Blue Shield ID card.
Is my coverage information available to my doctor for electronic prescriptions (e-prescriptions)?
Yes, your doctor can obtain information about your prescription benefit, including copays, what’s covered on your drug formulary, and what other prescription medications you have filled at a pharmacy in the Blue Shield network. By using e-prescription technology, your doctor can view information about potential drug interactions and side effects before prescribing new medications for you at the time of your visit. Your doctor can also choose medications that are covered on your prescription benefit and see what drugs are available as a low-cost generic before going to the pharmacy.
When your doctor uses e-prescription technology, once a prescription has expired, the pharmacy can automatically notify your doctor to renew it electronically, saving time and making it easier for you and your doctor.
Ask your doctor to transmit your prescriptions electronically to the pharmacy on your next visit to experience the benefits of e-prescriptions.
What is the Pharmacy and Therapeutics Committee?
Our Pharmacy and Therapeutics (P&T) Committee is made up of independent community physicians and pharmacists who are not Blue Shield of California employees. The P&T Committee reviews and updates the formulary list each quarter so that it includes safe and effective drugs approved by the Food and Drug Administration (FDA). The Committee reviews and updates medication coverage criteria to reflect current standards of practice. They also review and approve quality assurance programs to enhance Blue Shield's quality of care.
How often does the Committee review medications?
The P&T Committee meets quarterly to review new drugs that have received recent FDA approval, as well as drugs that have been FDA-approved for new medical conditions.
How does Blue Shield decide which drugs are on the formulary?
Our goal is to provide a formulary that gives members access to appropriate and cost-effective medications. The FDA-approved brand-name drugs in our formulary are selected based on their safety, effectiveness, and overall value. Brand-name drugs are added to the formulary if they represent an important therapeutic advance. They are not added if current drugs on the formulary are equally safe and more cost-effective.
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Page last updated: 10/01/2023