Pharmacy/Drug Coverage

The list of covered formulary medications chosen by the AZ Blue Pharmacy & Therapeutics (P&T) Committee, which is made up of community doctors and pharmacists. AZ Blue covers the medications listed on the formulary as long as:

• The medication is medically necessary and appropriate
• The medication has been approved by the Food and Drug Administration (FDA) for the diagnosis for which the medication has been prescribed
• The medication is not a benefit plan exclusion

Depending on the specifics of your benefit plan, other conditions may apply, such as requiring the medication to be filled at a AZ Blue network pharmacy. Additionally, covered medications are subject to limitations, including but not limited to, prior authorization, step therapy, quantity, age, gender, dosage, and frequency of refills.

Certain medications or medication classes are pharmacy benefit plan exclusions, including but not limited to the items below:

• Athletic performance
• Clinic packs
• Combination’ products, including:
  • Medications packaged with one other or multiple other prescription products
  • Medications packaged with over-the-counter medications, supplies, medical foods, vitamins, or other excluded products
• Cosmetic purposes
• Excluded Drugs List
  • Medications that only modify the dosage form (tablet, capsule, liquid, suspension, extended release, tamper resistant) for a medication that is already available in a common dosage form
  • Medications with one or more principal ingredients that are already available in greater/lesser strengths and/or combinations
• Experimental and/or investigational
• Fertility/infertility
• Lifestyle enhancement
• Medical foods
• Medical devices, unless specifically noted in the listing below
• Non-FDA approved, including DESI
• Off-label, unlabeled and orphan medications, unless specifically noted in the listing below
• Over-the-counter (OTC) medications that can be obtained without a prescription, unless specifically noted in the listing below and obtained using a prescription
  • Medications with primary therapeutic ingredients that are sold over the counter in any form, strength, packaging, or name
• Sexual dysfunction
• Unit-dose packaging, unless that is the only form in which the medication is available
• Weight Gain or Loss

Medications that exceed limitations, including quantity, age, gender, and refill limits, may not be covered. Coverage is not available for medications used to treat a condition not covered under your benefit plan. If a medication does not process at the pharmacy and you do not understand why, please contact us. Medications may reject for many reasons, including member eligibility, exclusion status, quantity, age, gender, dosage, and/or frequency of refill limitations.

If you need to verify medication coverage or requirements, refer to your benefit book or contact us.

Sometimes our members need access to drugs that are not listed on the plan’s formulary (drug list). These medications are often referred to as non-formulary medications. Non-Formulary medications are not covered unless an exception is made. Requirements are outlined in the ACA Non Formulary Medications Coverage Guideline.

Non-Formulary Exception Process
If a member or provider feels there are no suitable formulary alternatives available, he or she may request that an exception be made to allow coverage for a non-formulary medication by filling out the Pharmacy Prior Authorization Request Form and providing appropriate documentation supporting the request. Your doctor can submit the form and documentation by fax to 602-864-3126 or by email to pharmacyprecert@azblue.com.

A non-formulary exception request does not guarantee approval. Drugs that are not listed on the formulary below but are considered specific benefit plan exclusions will not be covered (see “What is Not Covered?”).

Formulary exception requests are reviewed within 72 hours from the time that the complete request has been received. If a request is marked as having exigent circumstances the exception request will be reviewed within 24 hours. An exigent request requires a written statement from the prescriber, explaining the reason for exigency.

These medications are initially reviewed by AZ Blue through the formulary exception review process. If your request is denied, you have the right to a review and detailed instructions will be provided on your denial letter.

Certain medications require approval prior to being obtained through your pharmacy benefits. This process is called prior authorization. A prior authorization request must be submitted and signed by your provider. Request forms are found at azblue.com. Click on the Resource Center tab, select Pharmacy, then select View resources for Standard Pharmacy Plans. The Pharmacy Prior Authorization Request Form is listed under the Forms and Resources section of the page.

Prior authorization requests are reviewed within 10 business days for standard requests. Requests noted by your provider as urgent are reviewed with request will be reviewed within 24 hours. An exigent request requires a written statement from the prescriber, explaining the reason for exigency.

The BCBSAZ Pharmacy and Therapeutics (P&T) Committee creates PCGs, which take into consideration the medical literature. The guideline may state specific limitations, including dosing, gender limits, age limits, or FDA indications for use. If the application of a guideline results in a non-covered claim, the provider has the option to appeal the decision.

Additional information about your pharmacy benefits can be found on azblue.com under Forms and Resources & PCG sections. This includes:

• Pharmacy Coverage Guidelines
• Prior Authorization Request Form
• Mail Order Enrollment Forms
• Prescription Medication Reimbursement information