1 blue Cross Community CentennialSM. 2018 Drug List This document contains information NTENNIALCARE about the drugs we cover in this plan This formulary is up-to-date through its publication date, July 1, 2018. blue Cross Community Centennial What is the blue Cross Community The first column of the chart has the name of the drug. Brand name drugs are capitalized ( , CIPRO) and Centennial drug list? generic drugs are listed in lower-case italics The drug list (sometimes called a formulary ) is a list ( , ciprofloxacin). showing the drugs that can be covered by your blue Cross The information in the Necessary actions, restrictions, Community Centennial health plan. The drugs listed will be or limits on use column tells you if blue Cross covered as long as you: Community Centennial has any rules for Have a medical need for them covering your drug.
2 Fill the medication orders at an in-network pharmacy The drugs are listed in categories, or groups, based on Follow the other rules of your blue Cross Community the type of medical conditions they treat. (For example, Centennial health plan drugs used to treat a heart condition are listed under Heart and Circulatory Drugs). For more information on how to fill your medication orders, please review your Member Handbook. You may also contact If you know what your drug is used for, look for the group blue Cross and blue Shield of New Mexico (BCBSNM) in the drug list. Then, look under that group for your drug. Member Services at 1-866-689-1523 (TTY/TDD 711). 2. Alphabetical Listing Look for your drug in the index at the back of this book.
3 What will I pay? Next to your drug, you will see the page number where In most cases you do not pay for covered drugs. Some you can find coverage information. members will have prescription copays depending on their category of eligibility. What are generic drugs? Can the drug list change? A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as Yes, it can change for various reasons such as a new, less the brand name drug, but often costs less. expensive generic drug becomes available. You will be told in writing when changes are made to Does the plan cover over-the-counter the drug list. (OTC) drugs? Yes, blue Cross Community Centennial covers certain OTC.
4 How do I use the drug list? drugs with a valid medication order from your health care There are two ways to find your drug in the list provider, and you may get those at no cost. Generic OTC. beginning on page 1. drugs are to be prescribed and filled by your pharmacy when 1. Category available. These OTC drugs must be filled at a pharmacy that The list of covered drugs that begins on page 1 gives you participates in the blue Cross Community Centennial network information about the drugs covered by blue Cross and for quantities up to a 30-day supply. Many of the OTC. Community Centennial . If you have trouble finding your drugs found on the drug list have an age restriction depending drug in the list, turn to the Index that begins at the back on what type of coverage you have.
5 Of this book. i Drug List Are there any limits on my coverage? Step Therapy: In some cases, blue Cross Community Added conditions or limits on some covered drugs Centennial requires you to first try certain drugs before another drug can be covered. For example if Drug A and may include: Drug B both treat your medical condition, the plan may not Prior Authorization: You or your provider may need to get cover Drug B unless you try Drug A first. If Drug A does not approval from blue Cross and blue Shield of New Mexico work for you, the plan will then cover Drug B. Medications (BCBSNM) before you fill some of your medication orders. that are subject to step therapy are identified in the drug Medications that require prior authorization are identified in list by an ST in the Necessary actions, restrictions, or the drug list by a PA in the Necessary actions, limits on use column.
6 Restrictions, or limits on use column. If you do not get What if my drug is not covered because I have not approval, blue Cross Community Centennial may not cover met the step therapy? (pay for) the drug. Contact BCBSNM Member Services at What if my drug requires a prior authorization? 1-866-689-1523 (TTY/TDD 711) and ask how you or Contact BCBSNM Member Services at your provider can submit a step therapy 1-866-689-1523 (TTY/TDD 711) and ask how you or exception request. your provider can submit a prior authorization You can also talk to your provider to decide if you (exception) request. should first try a different drug on our list that does not You can also talk to your provider to decide if you require step therapy.
7 Should first try a different drug on our list before you Morphine Equivalent (ME) Dosing: ME dosing is a tool request an exception. used to help prevent members from taking too much pain Quantity limits : For certain drugs, blue Cross Community medication (opioids). This tool allows BCBSNM to calculate Centennial limits the amount of a drug that will be covered the total daily dose of pain medications a member is taking for a period of time ( , no more than 60 tablets for 30 no matter which opioid they are prescribed. The current days). Medications that have quantity limits are identified in daily ME limit in New Mexico is 90 mg per day. If you are the drug list by a QL in the Necessary actions, taking a dose above ME90, you will need to get prior restrictions, or limits on use column.
8 Authorization (approval) from BCBSNM for blue Cross What if my drug is not covered because it exceeds Community Centennial to pay for the prescription(s). the quantity limit? Medications that have morphine equivalents are identified Contact BCBSNM Member Services at in the drug list by an ME in the Necessary actions, 1-866-689-1523 (TTY/TDD 711) and ask how you or restrictions, or limits on use column. your provider can submit a quantity limit You can find out if your drug has any other conditions or limits exception request. by looking at the drug list that begins on page 1. You can also talk to your provider to decide if you should first try a different drug on our list or different dose of your medication before you request an exception.
9 Ii blue Cross Community Centennial What if my drug is not on the drug list? Which drug categories are not covered Contact BCBSNM Member Services at 1-866-689-1523 by the Plan drug list? (TTY/TDD 711) and ask if your drug is covered. If you learn The following drug categories are not covered by your that blue Cross Community Centennial does not cover your blue Cross Community Centennial health plan: drug, you have two options: Anorexia, weight loss, or weight gain drugs Talk to your provider to decide if you should first try a Bulk chemicals different drug on our list before you request an exception. Cosmetic enhancing drugs Ask Member Services about making an exception to cover your drug. Member Services will tell you how you or your Diagnostic agents provider can ask for an exception to the drug list.
10 Drug Efficacy Study Implementation (DESI). These are drugs The date we last updated the list is shown on the that are not shown to be safe and effective. front cover page. Experimental and investigational drugs Erectile dysfunction drugs prescribed to treat impotence Specialty Pharmacy (SP) Drugs Fertility drugs Specialty drugs are certain prescription medications used to General anesthetic drugs treat complex, chronic conditions like cancer, rheumatoid Over-the-counter products not otherwise included on the arthritis and multiple sclerosis. Specialty drugs often require plan's drug list special handling (like refrigeration during shipping) and administration (such as injection or infusion). Specialty Surgical supply/medical devices pharmacy drugs require prior authorization before a blue Cross Community Centennial members who have dual prescription may be filled.