Whether you take medication to manage an ongoing health condition or you need a prescription for an illness, you will want to become familiar with your health care plan's drug list. This is a list of covered drugs that are available to BCBSTX members.
Both brand and generic medications are included on the drug list. The drug list has different levels of coverage, which are called "tiers." Generally, if you choose a drug that is a lower tier, your out-of-pocket costs for a prescription drug will be less.
The drug list is not a substitute for the independent medical judgment of your health care provider. The final decision on what prescription drug is appropriate for you is between your health care provider and you.
You can view your drug list here. Be sure to choose the section that describes your plan.
When You Can Request a Coverage Exception
If your medication is not on (or has been removed) from your drug list, you or your prescribing doctor may want to request a coverage exception.
To request this exception, your prescribing doctor will need to send us documentation. To begin this process, you or your doctor should call the Customer Service number listed on your member ID card for more information.
You can also fill out and submit the Prescription Drug Coverage Exception form . You will need to provide us with your doctor’s name and contact information as well as the name and, if known, the strength and quantity of the drug being requested.
BCBSTX will usually let you or your doctor know of the benefit coverage decision within the lesser of two business days or 72 hours of receiving your request. If the coverage request is denied, BCBSTX will let you know why it was denied and may advise you of a covered alternative drug (if applicable). You can also appeal the benefit determination (see below for more information).
You or your doctor may be able to ask for an expedited review if:
- You take medication for a health condition and failure to get that medication may either pose a risk to your life or health or could keep you from regaining maximum function.
- Your current drug therapy uses a non-covered drug.
If your review is expedited, BCBSTX will usually let you or your doctor know of the coverage decision within 24 hours of receiving your request. If the coverage request is denied, BCBSTX will let you know why it was denied and may advise you of a covered alternative drug (if applicable). You can also appeal the benefit determination.
How to Request a Reconsideration of a Drug Coverage Exception Determination
If your coverage request is denied, you may request a reconsideration through BCBSTX verbally by calling the telephone number on the back of your ID card or by written request to:
Blue Cross Blue Shield of Texas
P.O. Box 660044
Dallas TX 75266-0044
If your request is Urgent or Expedited, an external review with an Independent Review Organization (IRO) may be requested. If your case qualifies for external review, an IRO will review your case, at no cost to you, and make a final decision.
If your standard coverage exception reconsideration is denied, you may be able to request an independent, external review by an Independent Review Organization (IRO). To request an independent review, send your completed form to BCBSTX.
For questions about your rights, you may visit the Texas Department of Insurance website or contact:
Texas Department of Insurance Consumer Protection
Mail Code 111-1A, 333 Guadalupe
PO Box 149091
Austin, Texas 78714
If you have any questions about requesting a coverage exception, call the Customer Service number listed on your member ID card.