In most cases, a prescription drug may be covered under your pharmacy benefit. There are times, though, when a prescription drug is considered a medical benefit.
Medical Benefit Therapeutic Alternatives
Certain prescription drugs, given to you by a health care professional in a clinical or professional setting, have therapeutic equivalents or therapeutic alternatives that are used to treat the same condition. Your Blue Cross and Blue Shield of Montana health plan benefits may only cover select therapeutic equivalent or therapeutic alternative drugs.
Starting January 1, 2027, your BCBSMT health plan benefits will have a Medical Drug Benefit Program. This program defines benefits for those select therapeutic alternative drugs. It also adds coverage rules for:
- New-to-market drugs
- Drugs that received accelerated approval, by the U.S. Food & Drug Administration
- Drugs that can be self-administered (given to yourself)
- Drugs that may only be covered under the medical benefit for a set time, dose or number of treatments
These lists are subject to change.
What if my medication is not covered under my medical benefits?
The medication may be covered under your pharmacy benefits, based on your benefit plan.
If not, you, an authorized representative or your health care provider can call the number on your member ID card to ask for an exception. You and your provider will be told if the request is approved or denied.
Need more help?
- Visit our help center to get answers to health insurance questions.
- Register or log in to your Blue Access for Members℠ member account.
- Call us at the number on your member ID card.
Pharmacy vs. Medical Benefit
Medical Benefits
Drugs covered by medical benefits must be given to you by a health care professional in a health care setting.
Pharmacy Benefits
Drugs covered by pharmacy benefits are prescribed drugs you can take on your own.