2020 Pharmacy Benefits

2020 Pharmacy Benefits 

 

Your health plan's pharmacy benefit is now administered by OptumRx. The change took place Jan. 1, 2020. OptumRx is a Pharmacy Benefits Manager, an independent company that has been contracted by BlueChoice HealthPlan of South Carolina to provide certain services related to your health plan’s prescription drug coverage. 

Any questions about your pharmacy benefit can be answered by calling Member Services. Just call the number on the back of your member ID card.

Drug Tiers

Your Cost Drug Tier Usually Includes
$ Tier 1 Lowest-cost prescription generic and some over-the-counter drugs.
$$ Tier 2 Prescription generic and some over-the-counter drugs.
$$$ Tier 3 Brand-name drugs that don't have a generic available. Also may include higher priced generics that have more cost-effective options at lower tiers.
$$$$ Tier 4 Brand-name drugs that have brand or generic options at lower tiers. Also may include higher-priced generics that have more cost-effective options at lower tiers.
$$$$$ Tier 5 Specialty drugs* that are more cost-effective than other specialty drugs that treat the same conditions. Also may include some non-specialty brand or generic drugs that have more cost-effective options at lower tiers.
$$$$$$ Tier 6 Specialty drugs that have more cost-effective alternatives at Tier 5. Also, may include some non-specialty brand or generic drugs that have more cost-effective options at lower tiers.

*Specialty drugs are prescription medications that are used to treat complex or chronic medical conditions, such as cancer, rheumatoid arthritis, multiple sclerosis and hepatitis C.

Please note that if a plan has a brand deductible, any tier 3 or tier 4 medication will process to that deductible before applying benefits.

Vaccines

Effective immediately, you can get your seasonal flu vaccine covered at $0 copay through your pharmacy benefit by visiting any network pharmacy. Find a participating pharmacy with our Pharmacy Locator. Or, you can visit your primary care physician. Don't have one? Find one here.

You can also visit a participating pharmacy within South Carolina or the entire U.S. to get some non-seasonal preventive care vaccines at $0 copay. Below is a chart of these vaccines:

vaccine chart

 

Maintenance Drugs

Maintenance drugs are prescription drugs that are taken on a long-term basis. They may be used to treat a chronic condition or may be products taken routinely, such as birth control pills. Prescriptions for these products often can be filled for 90 days at a time. Some health plans may require 90-day fills for maintenance drugs. 

Some common maintenance drug categories/conditions include:

  • ADHD
  • Alzheimer’s Disease
  • Asthma/COPD
  • Blood Clots/Prevention
  • Benign Prostatic Hyperplasia (BPH)
  • Breast Cancer Prevention
  • Cholesterol/Lipid Lowering
  • Constipation
  • Contraceptives
  • Depression
  • Diabetes
  • Elevated Thyroid Hormone
  • Fibromyalgia
  • Glaucoma
  • Gout
  • Heart Failure
  • High Blood Pressure
  • Hormone Replacement
  • Inflammatory Bowel Disease
  • Irritable Bowel Disease
  • Neuropathic Pain
  • Osteoporosis
  • Overactive Bladder
  • Parkinson’s Disease
  • Potassium Replacement
  • Rheumatoid Arthritis
  • Seizures
  • Stroke and Heart Attack Prevention
  • Testosterone Replacement
  • Thyroid Hormone Replacement
  • Ulcers, Heartburn and Reflux
  • Vitamins