Pharmacy benefit tips for providers
Pharmacy Benefit Tips
For BCBSMT members with prescription drug benefits administered by Prime Therapeutics, BCBSMT employs a number of industry-standard management strategies to ensure appropriate utilization of prescription drugs. These strategies can include drug list management, benefit design modeling, specialty pharmacy benefits, clinical programs, among others. You can help us achieve these goals by:
1. Prescribing drugs listed on the drug list
The BCBSMT drug lists are provided as a guide to help in the selection of cost-effective drug therapy. Every major drug class is covered, although many of the drug lists cover most generics and fewer brand name drugs. The lists also provide members with criteria for how drugs are selected, coverage considerations and dispensing limits. While these drug lists are a tool to help members maximize their prescription drug benefits, the final decision about what medications should be prescribed is between the health care provider and the patient.
BCBSMT drug lists are regularly updated and can be found on the Pharmacy Program section of our website at bcbsmt.com/provider.
Note: For members with Medicare Part D coverage, the drug lists can be found on the plan’s website:
- Blue Cross Medicare Advantage: www.getbluemt.com/mapd/druglist
2. Reminding patients of covered preventive medications
Many BCBSMT health plans include coverage at no cost to the member for certain prescription drugs, women’s contraceptive products and OTC medicines used for preventive care services.*
- ACA $0 Preventive Drug List: www.bcbsmt.com/static/mt/pdf/rx/rx-aca-prev-list-mt.pdf
- Women’s Contraceptive Coverage List: www.bcbsmt.com/static/mt/pdf/rx/contraceptive-list-mt.pdf
*Not available for all plans. Members should call the customer service number on their ID card to help determine what benefits may be available, including any requirements, limitations or exclusions that apply. Please refer to the member’s certificate of coverage and prescription drug list as there may be coverage for additional products beyond these lists.
3. Submitting necessary prior authorization requests
For some medications, the member’s plan may require certain criteria to be met before prescription drug coverage may be approved. You will need to complete the necessary prior authorization request and submit it to BCBSMT. More information about these requirements can be found on the Pharmacy Program section of our website at bcbsmt.com/provider.
4. Assisting members with drug list exceptions
If the medication you wish to prescribe is not on your patient’s drug list or the preventive care lists, a drug list exception can be requested. You can call the customer service number on the member’s ID card to start the process, or complete the online form at: www.myprime.com/en/coverage-exception-form.html.
Visit the Pharmacy Program section of our website at bcbsmt.com/provider for more information.
Prime Therapeutics LLC is a pharmacy benefit management company. BCBSMT contracts with Prime to provide pharmacy benefit management and related other services. BCBSMT, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.