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There’s one question we often are asked: Is my prescription drug a pharmacy or medical benefit? In most cases, a prescription drug is covered under your pharmacy benefit. There are times, though, when a prescription drug is considered a medical benefit. Here is a breakdown to help you understand which is which.
Think about the common medicines you pick up at your local drugstore or have delivered to your home. Drugs that help keep your blood pressure or cholesterol in check. The cream your dermatologist gave you for that itchy rash. Antibiotics for a sinus infection. Or insulin to manage your diabetes. They’re just a few examples of prescription medicines you can take yourself that may be part of your pharmacy benefit.
Sometimes, medications must be given by a care provider in a health care setting. Birth control implants are one example. So are chemo infusions for cancer and immunotherapy for complex and chronic diseases. These types of medications usually require patients to be monitored by a medical professional during their treatment. Your medical benefit may cover the cost of the medication and its administration.
Vaccines given as part of preventive health care can be a pharmacy benefit or a medical benefit. A flu shot is the most common example. Its classification depends on your health plan and where you get the vaccine. Did you go to your local retail pharmacy for your flu shot? Or did your primary care provider give you a flu shot during your annual wellness check? The details determine which benefit category the flu shot may fall under.
Of course, understanding the details of your Blue Cross and Blue Shield of New Mexico (BCBSNM) plan is one of the best ways to get the most out of your pharmacy benefit. Here are some things you can do:
The list is exactly what the name suggests – a list of prescription drugs covered by your health care plan. The list is organized into different levels of coverage called member payment tiers. Some plans may have four tiers. Others can have up to six tiers. Each tier has its own cost. The lower the tier, the lower your out-of-pocket costs will be for the drug.
Generic drugs are usually found in the lower tier. Name brand drugs and specialty drugs are often in higher tiers. You may pay more for a brand name drug if a generic equivalent is available.
Talk with your doctor and pharmacist about all your medications. Always check to see if they are covered under your health care plan. For any name-brand drug, ask if there are generics or lower-cost alternatives you can take. If your drug isn’t covered on your Drug List, ask if there are other covered options.
You can check your drug list when you go to bcbsnm.com and log in to Blue Access for MembersSM (BAMSM).
BCBSNM works with a broad network of pharmacies. When you use an in-network pharmacy, your out-of-pocket costs are often less. You may also be able to get up to a 90-day supply of covered drugs you use regularly.
Sometimes, you may need to meet certain criteria before your prescription drug coverage is approved.
To review your pharmacy benefits, you can:
Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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