Blue Rx Value^SM

Welcome

We cover both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. Members may be required to pay more for a prescription when a brand-name product is dispensed.

What is a Formulary?

A formulary is a list of covered drugs which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

	Tier Designation
	Tier 1	Tier 2
Blue Rx Value 2 Tier	Tier 1	Tier 2
Blue Rx Value 1 Tier	Tier 1 and Tier 2 combined

Printable Files

To view a version of your Formulary Drug List with a screen reader, please click Printable Formulary below.

The following files require Adobe Acrobat. Download Adobe Acrobat

How to Search For Drugs

Use the alphabetical list to search by the first letter of your medication.
Search by typing part of the generic (chemical) and brand (trade) names.
Search by selecting the therapeutic class of the medication you are looking for.

How to Request an Exception

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:

You can ask us to cover your drug even if it is not on our formulary.

You can ask us to waive coverage restrictions or limits on your drug.

You can ask us to provide a higher level of coverage for your drug.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 72 hours after we get your prescribing physician’s supporting statement.

Common Drug Exclusions

Due to benefit design parameters, some plan sponsors may choose to exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded drugs may include, but are not limited to:

OTC drugs or their equivalents unless otherwise specified in the formulary listing.
Drug products used for cosmetic purposes
Experimental drug products, or any drug product used in an experimental manner
Replacement of a lost or stolen drug
Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA)

Notice of Nondiscrimination

Legend

TIERING

T1

- TIER 1
T2

- TIER 2
SP-P

- SPECIALTY PREFERRED
RX-DME

- PHARMACY DURABLE MEDICAL EQUIPMENT
P&T

- NOT COVERED AWAITING P&T REVIEW
SP-M

- SPECIALTY MEDICAL
NF

- Non-Formulary

Edits

QL

- Quantity Limit
PA

- Prior Authorization
AL

- Age Limit
SBG

- Specialty Biosimilars and Specialty Generics
S

- Specialty Drug
MN-PA

- Medically Necessary Prior Authorization
QLV

- Quantity Limit (Varies)
PA-QL

- Post-Quantity Limit Prior Authorization
PAv

- PAv
PV

- Preventive

Brand Names

generic names

Drug Name Search

By Therapeutic Class

Blue Rx ValueSM