BlueRx Drug Formulary Plan
BlueRx is designed to help control benefit expenses. We've designed the benefits so that there are safe and cost-effective treatment options, and access to limited benefit drugs when medically necessary.
When BlueRx plan members fill their prescriptions, the pharmacy submits the claim to Pacific Blue Cross (PBC) electronically via our BlueNet system. The pharmacist will be able to advise the member immediately if the prescribed medication is a limited benefit drug (which will require prior approval).
The BlueRx drug plan divides all medications into three categories: benefits, limited benefits and non-benefits.
Benefits
BlueRx covers most prescription drugs and some life-sustaining non-prescription drugs (such as nitroglycerin and insulin).
Limited Benefits
To ensure that a patient meets special therapeutic criteria established for a prescription drug, some BlueRx drugs are classified as limited benefits. Prior approval must be obtained from PBC before these particular drugs can be considered eligible for coverage. To obtain approval, the member is responsible for having their physician complete a BlueRx Prior Approval form and mail or fax the completed form to the PBC Extended Health Care (EHC) department. The forms will be reviewed against specific therapeutic guidelines and we will inform the member and their physician in writing of our decision regarding eligibility under their BlueRx plan.
Limited benefit drugs that require prior approval include:
**NOTE: Prior approval for limited benefit drugs is only required if you have coverage under the BlueRx formulary. Members of a BlueRx plan will receive PBC Extended Health Care cards with the words BLUENET/BLUERX appearing on the bottom of the card. An example of the card is reproduced below:
If you are still not sure if your drug coverage is the BlueRx plan, contact your Plan Administrator or Pacific Blue Cross.
A complete list of limited benefit drugs requiring prior approval can be found here
Non-Benefits
These drugs are not covered under the BlueRx plan. The list includes drugs that are:
- prescription cough and cold medications
- available without a prescription
- available free from other agencies
- used for cosmetic reasons
- used to treat an addiction or habit
- used to treat fertility problems
- oral contraceptives
- vaccines and preventative medications
- erectile dysfunction drugs
For more information about BlueRx, contact your Plan Administrator, Advisor or Pacific Blue Cross.