Drug benefits and claims FAQs
A prescription copayment and/or coinsurance, is the portion of the covered drug that you are required to pay each time you fill a prescription. Blue Shield pays the remainder. Usually the copayment is a flat dollar amount, and the coinsurance is a percentage amount of the drug cost. There are usually different copayments for the generic, brand formulary, and brand non-formulary drugs (if your plan has a benefit for non-formulary drugs). Check your Evidence of Coverage (EOC) or Certificate of Insurance (COI) for your specific copayment information.
Some plans have a benefit to include coverage of non-formulary drugs. Check your Evidence of Coverage (EOC) or Certificate of Insurance (COI) to find out if your plan covers these drugs. You may have coverage subject to higher copayments and/or copayment percentages. If your plan does not cover non-formulary drugs and you have tried the formulary alternatives, or changing to a formulary drug would be inappropriate, your physician may contact Pharmacy Services to request prior authorization. You may also request prior authorization by contacting Blue Shield Customer Care at (800) 443-5005, or (TTY at (800) 241-1823).
When a physician prescribes a brand-name medication, you should ask if a generic drug is available to treat your condition. If a generic drug is not available, your copayments will be lower if your physician selects a formulary over a non-formulary brand-name drug.
Some plans may have a pharmacy benefit deductible, which is the set dollar amount which you must pay each calendar year for covered prescriptions before your copayments, and/or coinsurances apply.
Check your Blue Shield of California ID card; you will see a "Yes" under “RX” if you have a prescription drug benefit. You may also call Customer Care to find out if you have a prescription drug benefit.
If your medication is due to be refilled while you are on vacation, you can have it filled at one of Blue Shield’s 68,000 participating pharmacies nationwide. Depending on your pharmacy benefits, you may also be able to call us and request an early refill authorization at your regular pharmacy, which will allow you to pick up your prescription before you leave town. To request an early refill authorization, please call the number on your member ID card. If you use our mail order pharmacy, you can also request that your refill be shipped to a different address while you are traveling.
Here are some tips about traveling with medication:
- Bring a list of your prescription drug and over-the-counter medications along with the frequency and time you take them. If you are unexpectedly admitted to the hospital, give this list to hospital staff, as it will help doctors understand your condition(s).
- If you are vacationing in a different time zone, make sure you adjust the time of day you take your medications accordingly. Remember, once a day means every 24 hours so you may need to change the time you take your daily medications.
- Always keep your medication in the labeled bottles given to you by the pharmacy. This is especially important when you are flying.
- Always keep medication in your carry-on bag, even if your flight is short. Your luggage could be lost or stolen or there could be unexpected delays.
- Always bring more medication than you expect to need. You may have unexpected delays getting home.
- Ask your pharmacist if there are any foods or beverages that conflict with your medication. You may be more inclined to try unfamiliar foods, especially in foreign countries or big cities.
There are a few safe ways that you can dispose of your old prescription medications. It is important to use these methods, and avoid simply tossing the unused drugs into the trash, or flushing them down the toilet because drug residues can end up in water systems, and in drinking water reservoirs.
The US Food and Drug Administration (FDA) recommends the following for safe disposal:
- Drop off your unused medication at a drug take-back program site. Visit the California State Board of Pharmacy’s Drug Take-back website to find disposal locations near you, and when Drug Enforcement Administration (DEA) National Prescription Drug Take-back days are scheduled.
- Prepare unused medications so you can dispose of them safely in the trash. The FDA provides instructions on how to do this. For additional information you can visit the FDA website.
"Participating pharmacy" is a pharmacy that has an agreement with Blue Shield to provide covered services to our members.
Most drug benefits do not include coverage for non-participating pharmacies, unless the prescription is obtained in conjunction with a covered emergency. If you fill your prescription at a non-participating pharmacy, you must pay the pharmacist for the entire cost of the prescription up front and then submit a claim form for reimbursement. If the claim is approved, your copayment or coinsurance may be more than you would have paid if you had used a participating pharmacy. Depending on the design of your benefit, you will also be responsible for any penalties, deductibles, and applicable copayment/coinsurance. Check your Evidence of Coverage (EOC) or Certificate of Insurance (COI) for your specific copayment information.
There are a few circumstances when you need to file a prescription drug claim:
- If you have filled your prescription at a non-participating pharmacy, you can submit a completed claim form along with a detailed receipt. (Check your Evidence of Coverage (EOC) or Certificate of Insurance (COI) to determine if this applies to your plan). Reimbursement will be based on whether Blue Shield covers the medication and any applicable copayment, coinsurance percentage, copayment penalty, and/or pharmacy deductibles. You can obtain additional claim forms by contacting the Customer Care phone number listed on your Blue Shield ID card.
- If you are a new member who did not receive a Blue Shield ID card during the first 30 days of becoming a Blue Shield member and you need a prescription, you may pay the pharmacist for the entire cost of your prescription and then submit a claim form to Blue Shield to receive reimbursement for any covered medication.
We will generally process your pharmacy claim within 21 business days of when it is received. If your claim is approved, you can expect a reimbursement check within 4 to 6 weeks from when we received your claim.