Pharmacy/Drug Coverage

Benefits and cost sharing for prescription medications vary depending on your benefit plan terms, the medication prescribed, and whether the medication is obtained at a retail pharmacy, a specialty pharmacy, or a mail order pharmacy. Please consult the member benefit plan book and Summary of Benefits and Coverage (SBC) for a complete description of the prescription medication benefit. If the information in this section differs from the applicable benefit plan, the terms of your benefit plan apply.

If your plan does not cover a medication and you obtain it, you will have to pay the full cost of the medication and costs incurred for non-covered medications are not applied to the deductible or out-of-pocket-maximum.

No exceptions will be made regarding the assigned tier of a medication.

Medications may change tier throughout the course of the year. AZ Blue’s Pharmacy and Therapeutics (P&T) Committee meets on a quarterly basis to review recommended changes and make determinations. Members will be notified of any changes as required by law.

A medication may change tiers for a variety of reasons, including but not limited to:

• Recommendation by the AZ Blue P&T Committee
• Availability of a new generic option
• New clinical information

Distribution limitations may apply.

• Retail—AZ Blue uses Optum’s National Network. Generally, all major pharmacy chains operating in Arizona are contracted to provide retail pharmacy services for AZ Blue members. Certain benefit plans may offer a limited network that excludes CVS and Target.
• Mail order—AZ Blue does not provide out-of-network mail order pharmacy benefits. OptumRx® Home Delivery Pharmacy is AZ Blue’s exclusive mail order pharmacy provider. Complete the Mail Order Pharmacy Form on azblue.com to get started.
• Specialty medications—Certain medications may require specialty distribution, provided through our exclusive provider Optum Specialty Pharmacy. These medications are covered up to a 30-day supply and include self-injectable, oral, topical and inhaled medications. Specialty medications cannot be filled at retail pharmacies. Please contact Optum Specialty Pharmacy directly at (877) 850-7071 to establish service with them.

If you are currently obtaining a Specialty Medication from a Specialty Pharmacy and need to receive that medication from a retail pharmacy instead, please contact the Pharmacy Benefit Customer Service number listed on your ID card. AZ Blue and/or the PBM will decide whether you are eligible to receive the Specialty Medication from a retail pharmacy instead of a Specialty Pharmacy.

• Open Multi-Tiered Drug List – Instead of requiring members to adhere to a strict formulary program, AZ Blue offers a multi-level copay benefit design providing coverage for all drugs (with the exception of plan exclusions) at varying levels. As a result, this benefit design incentivizes physicians and members to make the most cost-effective choice about prescription drugs for each member through copay differentials.

  Most, but not all, generic drugs are covered on Tier 1 with the lowest cost share. Generic products that are combinations of two medications as well as extended or sustained-release products may be included on higher copay tiers. Preferred brand drugs are covered on Tier 2, and nonpreferred brands are covered on Tier 3 and/or Tier 4.

• Premium Preferred Drug List (PDL) Closed Formulary – The AZ Blue Premium PDL is a closed formulary designed to minimize disruption while maximizing value. On the Premium PDL, AZ Blue recommends a 4-tier retail plan design and coverage of Specialty Medications in 4 distinct specialty tiers. We maximize value and minimize spend through utilization management and targeted exclusion strategies to remove certain medications from coverage. For example, new-to-market products are excluded at launch until AZ Blue’s Pharmacy & Therapeutics (P&T) completes a review, helping avoid potential member disruption. This value-driven formulary includes our standard, complete utilization management (UM) suite, supporting medication safety and clinical efficacy while focusing on lowest cost.
• Affordable Care Act (ACA) Closed Formulary – An affordable care act plan is an insurance plan that’s certified by the Health Insurance Marketplace®, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act. All affordable care act plans meet the Affordable Care Act requirement for having health coverage, known as “minimum essential coverage.” A formulary is list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. (These definitions are based on the Glossary on healthcare.gov).

Many benefit plans require you to purchase a generic drug if one is available. If you purchase a brand name drug when a generic is available you may have to pay the tier 1 copay plus the difference between the allowed amount for the generic and the brand name medication, even if the prescribing provider indicates on the prescription that the brand name medication should be dispensed. Exceptions are made when a medication is approved through step therapy if all alternative medications have been tried and failed, or when AZ Blue requires the brand name medication to be utilized as the preferred medication. Please refer to your benefit book to determine how this program applies to your plan or contact the pharmacy customer service phone number on the back of your ID card with any questions.