Pharmacy Benefits Explained

June 27, 2024

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Understanding your health insurance and how it works is key to getting the most from your health plan. We have shared how an Explanation of Benefits (EOB) can help you know how your health insurance is applied to medical bills and why health insurance is important overall. 

Some of the most common questions we get are about pharmacy benefits. 

What are pharmacy benefits? 

Every health plan is different. Plans can be customized based on how you get your health coverage. For example, some people get health insurance through their employer, and others might purchase it through the health care marketplace. 

Your BlueCross BlueShield of South Carolina health plan may include pharmacy benefits to help you get the drugs you need at the lowest cost. If your pharmacy benefits are included with your BlueCross plan, you'll use the same insurance card at the doctor and pharmacy. You'll also see pharmacy information under the Benefits section of your online member portal My Health Toolkit® account.

The pharmacy decisions for our health plan are called the formulary. The formulary includes the drugs our health plans cover.

Who makes pharmacy benefit decisions for BlueCross? 

An independent pharmacy and therapeutics committee of physicians from South Carolina determine pharmacy benefits for BlueCross health plans. 

Why do we have a pharmacy group to make decisions about these benefits? 

By having an external committee, we ensure a consistent and standard process of assessing medications that are on the market. 

This group is responsible for making sure we have the best medications available to care for the people we serve. This means that the drugs treat the conditions they are prescribed for. It also means there is data to support their use. 

We want to ensure that all of the medications we cover meet scientific standards. Sometimes drugs are put into the market before there is sufficient data. But our pharmacy group reviews and requires comprehensive data before any medication is added to the formulary.   

How does this process benefit members? 

Because the review group is separate from BlueCross and includes experts who currently practice medicine, it provides unbiased, informed decisions to provide the best care for our members. 

Why are some drugs not covered by insurance?  

There are many drugs on the market to treat a given condition. Some drugs might not be covered because lower-cost drugs are available to treat the same condition. The drugs on our formulary are both clinically appropriate and cost effective. We would not remove a drug from our formulary unless we believe there is an alternative option that would be more appropriate for our members. 

Why do pharmacy benefits change?

New data comes out as drug companies study medications. This can change the drug recommended for treatment by medical professionals. Our formulary changes because the drugs available on the market do. In recent years, the U.S. has faced drug shortages*. Our formulary takes into account which drugs can sustain our members’ demand. 

Why do some plans require 90-day refills? 

One way to help patients with chronic conditions such as diabetes and hypertension take their medications as prescribed is to require them to have 90-day supplies of these drugs. With a larger supply, people will be less likely to miss a dose. A 90-day supply cuts down on the number of refills and trips to the pharmacy. It is meant to help our members better manage their conditions.  

Why do some plans require people to use certain pharmacies? 

Because every plan is different, pharmacy requirements vary by plan. Some health plans may require a specific pharmacy because that pharmacy is able to give our members a deeper discount on the cost of the drugs. 

Why does the cost of drugs keep going up? 

Costs are rising in all sectors of our economy. We continue to see an increase in the cost of pharmacy drugs*. The development of drugs is expensive, especially in specialty areas. 

In the past, more generic drugs were available. But now, there are more brand-name products, which are often higher in cost. 

How can members save money on their medications? 

Some drug companies offer coupons, but this is dependent on the manufacturer. There are also subsidies and coupon assistance for some drugs. 

Members should use the pharmacy their plan recommends. Often this comes with savings to the member. You can find information about your specific pharmacy benefits in My Health Toolkit, our member portal. There’s even a drug pricing tool to help you compare costs by pharmacy location or see if you could save money by switching to mail order.  You can find the answer to most health plan questions in the portal. 

Whom do I call if I need help with my drug benefits? 

If you have coverage questions, you can call the customer service team at BlueCross to help. The number for your health plan is on the back of your ID card. You can find a digital copy of your ID card in My Health Toolkit. You can also visit My Health Toolkit to view details for pharmacy claims and prescription drug benefits. 

Can I appeal for a drug to be covered? 

Yes. Members can request that drugs not included in our formulary be allowed based on medical necessity. Members have the right to appeal if a decision is denied. Our pharmacists and medical directors review each request. Sometimes we send these appeals for external review by specialists. 

Members can learn how to submit an appeal through My Health Toolkit. 

What should members know about their pharmacy benefits? 

Just as you should understand your health plan overall, you should know your pharmacy benefits. You can use the pharmacy tools in My Health Toolkit to understand what is covered, see if you have a deductible and find other resources. 

Before picking a health plan during open enrollment or special enrollment periods, you should consider the cost of any medication you take regularly. 

*This link leads to a third-party website. That organization is responsible for the content and privacy policy on its site.

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