Preguntas frecuentes sobre medicamentos con receta y farmacias

A drug list is a list of drugs that your plan covers. It explains what tier (or coverage level) each drug is in and any requirements for that medicine, like prior authorization or dispensing limits. Drugs on the list are based on the recommendations of a group of experts with a medical or pharmacy degree. They look at safety, cost and how well the drugs work. Revisan y actualizan las listas regularmente. Cada medicamento de la lista está aprobado por la Administración de Alimentos y Medicamentos de los EE. UU. (FDA, en inglés).

If the medicine you take isn’t on the drug list, it may not be covered by your pharmacy benefits.

Explore the BCBSNM drug lists.

We strive to provide our members with access to quality, cost-effective treatment options. Drug lists help us manage the rising costs of prescription drugs for you and us. Routinely reviewing these drug lists helps us keep health care more affordable for our members.

Drug lists are updated regularly. They might be updated monthly, quarterly or annually, based on your plan benefits. Newly released drugs, updated clinical or regulatory guidelines, drug costs and changes in the drug market are all possible reasons the drug lists may change.

If your medicine is removed from your drug list, you may get advanced notice from us. Sometimes, a drug might be moved to a different tier. The drug is still covered but at a higher or lower payment level. If a drug you take is moved to a higher tier, you may get advanced notice from us.

If your medicine has a coverage update:

• Talk with your doctor or pharmacist. They may be able to offer another option. It’s important that you don’t stop taking your medicine without talking with your doctor or pharmacist first.
• Your doctor can ask for a coverage exception (if benefits allow) from your health plan. Las decisiones sobre su tratamiento las toman siempre usted y su médico.

If you’ve been told a prescription medicine isn’t covered, the first step is to find out more:

•  Ask your pharmacist.
• Check to see if it might be a paperwork issue, like not getting pre-approval, also called prior authorization.
• Have your doctor review the drugs on your drug list.

Visite nuestra página Transparencia en cobertura page to learn more. There might be other options that are covered by your plan, like a generic drug. Or, if your benefits allow, your doctor might be able to ask for an exception to cover your medicine.

In all cases:

• Las decisiones de tratamiento las toman usted y su médico. Ask your doctor about your therapeutic or generic options. There may be a lower-cost alternative available.
• You can pay for the medicine out-of-pocket, often at a higher cost. Talk to your pharmacist to see if there may be other ways to save money on your medicine.
• Your doctor can ask for a coverage exception (if benefits allow) or a clinical review from your health plan.
• If the request is denied, you or your doctor can appeal the decision.

La mayoría de las listas de medicamentos tienen grados de cobertura, llamados niveles. Drugs are placed into these tiers based on defined categories. Cada nivel tiene su propio costo. Some pharmacy benefit plans may have up to 6 payment tiers. Some plans may have fewer tiers, such as all generics in one tier. Drug tiers help manage the cost of medicine for you and us.

There are a few ways to find out if your prescriptions are part of your plan's drug list:

• Si es asegurado de BCBSNM, inicie sesión en su cuenta de asegurado en línea. The Pharmacy tab has a medicine search tool. You'll find information about that drug, including coverage and cost details.
• If you’re shopping for coverage or know the name of your plan and drug list and don’t want to log in to your account, you can search the BCBSNM Drug Lists page.
• When in doubt, talk with your doctor or pharmacist. They can help you figure out the medicine that's best for you and go through any extra insurance steps, like requesting prior authorization.

The drug search tool in your BCBSNM online member account can help you estimate how much you might pay out-of-pocket for a covered medicine. Plus you can find out which pharmacies offer the best price or discounts under your plan.

When you log in to your account and start searching for a drug, you’ll get an estimated cost based on your specific plan benefits, how much of your deductible you’ve used and nearby pharmacies to fill your prescription. 

Algunos medicamentos recetados necesitan aprobación antes de que su cobertura los pague. La autorización previa ayuda a garantizar que el medicamento se recete, se administre y se tome de manera segura.

If your drug is part of this program, your doctor will need to submit information before it will be covered. Si se aprueba, usted pagará su parte del medicamento según su cobertura. Si no se aprueba, el medicamento no estará incluido en su cobertura. You can still get your prescription, but you may have to pay the full amount.

Las decisiones sobre su tratamiento las toman siempre usted y su médico. Obtenga nuestro folleto para asegurados para ver más detalles.

La mayoría de las veces, su farmacéutico le notificará si una receta médica necesita autorización previa. También se puede registrar en su cuenta de asegurado en línea, click on the Pharmacy tab and search for a medicine. The search results will, say if the drug needs prior authorization.

If you know the name of your plan’s drug list and don’t want to log into your account, you can get the list of medicines that need prior authorization .

A team of doctors and pharmacists reviews drugs to decide which ones need prior authorization. They review the drugs labels approved by the FDA, they also review scientific studies and national guidelines. Utilizan esta información para tomar decisiones fundamentadas.

Usually, your doctor will take steps to start the prior authorization process. They should work with us to file any required paperwork. Encontrará más información en la página autorización previa process on our website. 

If your prior authorization request is approved, you'll pay your cost share for the drug based on your benefits. Si no se aprueba, el medicamento no tendrá cobertura. Todavía puede surtir la receta, pero tendrá que pagar el monto total. You can also work with your doctor to go through an appeals process if your request is denied.

Cost is only one factor in choosing a medicine. Las decisiones sobre su tratamiento las toman siempre usted y su médico.

If your prior authorization is denied, it means the drug won't be covered under your benefit plan. Here are the most common reasons it may be denied:

• It wasn’t deemed medically necessary. Some drugs can be misused, overused or may not be the best choice for your medical condition. Your doctor can help you with a letter of medical necessity to explain why a certain prescription is needed.
• You need to try an alternative medicine. A more affordable medicine might be covered instead, like a preferred brand or generic option. If it doesn’t work for you, your doctor can explain why the originally prescribed drug is needed.
• There were administrative errors. Maybe we’re missing a document, the wrong diagnosis code was typed in, or we need some more clarification. 

When you get a denied prior authorization request, you can:

• Review the denial letter and reason given with your doctor.
• Submit an appeal, ask for a second review or check on clinical alternatives.

Dispensing limits are rules around the amount of a prescription drug you can fill at a pharmacy during a certain period of time. Los límites suelen basarse en el etiquetado aprobado por la FDA y otros factores. Usted y su médico pueden decidir que necesita más cantidad de un medicamento de lo que permite el límite de dispensación. En ese caso, aún puede obtener el medicamento. But you may be responsible for the full cost of the drug beyond what your benefit plan allows, unless your doctor asks for approval.

When you log in to your online member account, click on the Pharmacy tab and search for your medicine. The search results will show any dispensing limits. Your pharmacist may also notify you if your prescription is over the límite de expendio.

If you want to see if a covered medicine has a dispensing limit without logging in to your account, you can review the dispensing limits summary.

Dispensing limits help make sure drugs are used the way the FDA has approved.  and reduce waste of medicine. Por ejemplo, el medicamento para el síndrome del intestino irritable Trulance® (plecanatida) solo se puede surtir en 30 comprimidos para 30 días, ya que la etiqueta aprobada por la FDA recomienda una dosis de un comprimido de 3 mg al día por vía oral.

Los suministros diarios se refieren al número de días que durará su medicamento con receta. This can be a few days, for example, a 10-day supply for a short-term prescription like an antibiotic. Or it may be longer for a drug taken every day, like a 30-day or 90-day supply.

Los límites de suministro diario forman parte de sus beneficios farmacéuticos. Your plan may only allow a 30-day supply of your prescription or limit how many refills are allowed. Consulte los materiales de su cobertura para conocer los límites de suministro diario.