Pharmacy Frequently Asked Questions

  • What is the Prescription Drug 3-Level Benefit?

    In Premera’s leveled pharmacy structure, prescriptions fall into one of three categories

    • Level 1 (lowest copay) – generic drugs
    • Level 2 (moderate copay) – preferred brand-name drugs
    • Level 3 (highest copay) – non-preferred brand-name drugs

    How will I know if my medication is Level 1, 2 or 3?

    Search the Preferred Drug List to find out if your prescription drugs are in level 1, 2 or 3.

    How can I be sure to pay the lowest possible copay?

    Generic drugs offer the lowest copay. Ask your healthcare provider if there is a generic drug that is right for you. If there is no generic available, a level-2 preferred brand-name medication may be a good alternative.

    What if I take a non-preferred brand-name drug and I want to remain on that medication?

    As always, the medications you take are your choice. If your healthcare provider decides you should use a preferred brand-name drug for medical reasons, you pay only the applicable copay. If you chose to stay on a non-preferred brand-name medication when a generic is available, the level-3 copay will apply.

    What is the Pre-approval Program?

    If you take medications for certain conditions – including migraines, diabetes, high blood pressure, asthma and gastrointestinal reflux disease – you may need to meet certain requirements before your prescription is covered.

    Read more detailed information.

    What drugs are included in the program?

    View a complete list of medications and drug classes included in the program.

    How are medications chosen for the Pre-approval Program?

    Medications are reviewed by an independent Pharmacy and Therapeutics Committee which makes recommendations based on clinical criteria. These recommendations inform Premera’s decision to include specific medications in the program to promote appropriate, safe and effective drug use.

    How does the Pre-approval Program work?

    • When your prescription is submitted by your pharmacy, our computer system checks the prescription drug therapy to see if it meets Pre-approval Program guidelines
    • If it meets the guidelines, your prescription is filled without interruption
    • If it does not meet the guidelines, your prescription is filled at the pharmacy one time
    • Before your next refill, we’ll send you a letter and fax-back form that you’ll need to take to your healthcare provider
    • If your healthcare provider wants you to continue with the same drug therapy, he or she can fax the form to our Pharmacy Service Center
    • Our review process takes 1-2 business days. Once we’ve received your healthcare provider’s information, we’ll send you a letter confirming the decision made regarding your drug therapy. Your prescription can be filled on the same day an approval decision is made

    When filling a prescription for a medication in the Pre-approval Program, you may choose to pay the full retail cost out-of-pocket, without coverage from your Premera benefits, if you choose not to follow the program guidelines.

    Why is an authorization required for certain medications?

    We are concerned about safe use of medications for our members. This program makes sure you are using only medication you need, for the most effective duration and dosage. Your healthcare provider always makes the final decision on which medication is appropriate for your treatment.

    What is changing with the Preferred Specialty Pharmacy Program?

    Specialty drugs, such as self-injectables, are only covered if purchased through Accredo, an Express Scripts specialty pharmacy 800-689-6592

    Please note: this change does not apply to doctor-billed specialty drugs.

    I have a prescription with another specialty pharmacy. Will I need to get a new prescription from my healthcare provider?

    There are three ways to switch to Accredo:

    • Ask your current pharmacy to transfer your prescription(s) to Accredo Specialty Pharmacy
    • Ask Accredo Specialty Pharmacy to contact your healthcare provider directly for new prescription(s)
    • Ask your healthcare provider to fax or call in your new prescription(s) to Accredo Specialty Pharmacy

    What if Accredo Specialty Pharmacy doesn't carry my medication? How will my medication be covered?

    In rare cases, there may be specialty medications that are available through a limited network or through one exclusive specialty pharmacy. These limited or exclusive specialty drugs are not included in the preferred specialty pharmacy program. You will receive coverage for these medications at the pharmacy that carries your medication.

    What drugs are part of the Preferred Specialty Pharmacy Program?

    Only specialty drugs that are available at Accredo Specialty Pharmacy are included in the preferred specialty pharmacy program. View preferred specialty drug list.

    Who can I call if I have more questions?

    If you want more information about any of the pharmacy benefits and programs, or how they affect your medical plan, please call Premera Blue Cross Customer Service at 877-224-3525.