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Health plans cover a wide range of medications. But they don’t cover them all. Often, other drugs on the drug list, branded or generic, are used to treat the same condition and may be a lower cost.
If you’ve been told a prescription medicine isn’t covered, the first step is to find out more. Learn why the medicine is not covered. Ask the pharmacist. Check to see that it’s not a paperwork issue, like not getting pre-approval, also called prior authorization. If your drug needs to be given to you by a health care provider and in a hospital, office or health care setting, it may be covered under your medical benefit instead.
What you do next depends on why the prescription may not have paid under your pharmacy benefit.
In all cases:
Lists of covered drugs, also called formularies, change. These lists are routinely reviewed so covered drugs can change from time to time. If your prescription isn't covered because it isn't on the drug list:
Your prescription isn't covered because it's on the Prior Authorization or Step Therapy programs list:
Your prescription isn't covered because it's FDA-approved for a health problem you don't have:
Remember, you or your doctor can check in advance to find out if a drug is covered and if there are any special rules. .
You can check your prescription benefit information. Log in to your Blue Access for MembersSM (BAM)SM account. Select the Coverage and Benefits tab, and click on Pharmacy, then Manage Prescriptions and Benefits. Or to check your drug list, see Prescription Drug Lists at bcbsnm.com. Select Prescription Drug Lists, then choose your plan type.
Or, you or your doctor can check with us at the phone number listed on your member ID card.
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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