Drug Policies and programs
A wide network of pharmacies
Blue Medicare Advantage plans offer a wide network of pharmacies across the country and provides coverage for prescription drugs in different therapeutic areas. Use our search tools below to locate a pharmacy and to look up coverage information for a specific drug.
Find a pharmacy External Link Find a Drug List (Formulary) External Link
Drug programs that save you money
We work hard to keep medication prices down, because people who take their medications as prescribed have better health outcomes. Our drug programs ensure you get the greatest level of care at a lower cost to you.
The utilization management program is designed to manage the use of certain prescribed drugs, ensuring you get the right drug for your specific needs — which will help lower your prescription drug costs.
Every time you fill a prescription, we review your records to make sure your prescriptions are safe and appropriate. We do this for all our members on a regular basis. These reviews are especially important if more than one doctor prescribes medications for you.
We look for issues such as:
- Possible medication errors
- Drugs that are unnecessary because you're taking another drug to treat the same medical condition
- Drugs that aren't right for you because of your age or gender
- Possible harmful interactions between two drugs
- Drug allergies
- Errors in the dosage for a drug you are prescribed
If we see a problem, we work directly with your doctor to correct it.
The utilization management program includes:
- Step therapy
- Prior authorization
- Quantity limits (for example, we may only approve a 30-day supply of some drugs)
- Authorizing the substitution of a generic drug for a brand-name drug as permitted
You can find out if the drug you take has any of these restrictions by looking in your plan's drug list, also called a formulary, or calling the pharmacy services number on the back of your Wellmark Advantage Health Plan ID card.
If, because of medical necessity, you can't meet a restriction, you or your doctor can request an exception by filling out the coverage determination form PDF File.
Call 24 hours a day, 7 days a week:
- Pharmacy Services for Wellmark Advantage Health Plan HMO: (TTY: 711)
- Pharmacy Services for Wellmark Advantage Health Plan PPO: (TTY: 711)
Step therapy is a type of prior authorization that ensures lower drug costs for you by starting with a lower cost drug option before "stepping up" to a higher cost drug. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
Step therapy paired with care coordination ensures lower costs for you and improves the quality of care you receive.
How do I know if a prescription requires step therapy?
Start by looking at your drug list (formulary) for an ST after the name of your prescription. This signifies that the drug requires step therapy. You can also check out the step therapy criteria for a prescription drug on the Comprehensive Drug List (Formulary) Prior Authorization/Step Therapy Program PDF File list.
What if my prescription requires step therapy?
You or your pharmacist should tell your doctor. There may be another drug they can prescribe that doesn't require step therapy. If not, you can call the pharmacy services number on the back of your Wellmark Advantage Health Plan ID card to start the approval process. You can also start the approval process by filling out and sending in a coverage determination form PDF File.
Call 24 hours a day, 7 days a week:
- Pharmacy Services for Wellmark Advantage Health Plan HMO: (TTY: 711)
- Pharmacy Services for Wellmark Advantage Health Plan PPO: (TTY: 711)
Because we care about your safety, some prescriptions need an additional review — or a prior authorization — to ensure you're getting the right medication.
Why would a drug need prior authorization?
Here are reasons certain drugs require a prior authorization:
- The drug has dangerous side effects or can be harmful when combined with other drugs.
- The drug should be used only for certain health conditions.
- The drug is often misused or abused.
- There are less expensive drugs that might work better.
- To determine whether the drug is covered by Medicare Part B or Part D.
How do I know if a prescription requires prior authorization?
To find out if your drug requires a prior authorization, check your plan's drug list, also called a formulary, and look for a PA after the name of your prescription. You can also check out the prior authorization criteria for a prescription drug on the Comprehensive Drug List (Formulary) Prior Authorization/Step Therapy Program PDF File list.
Call 24 hours a day, 7 days a week:
- Pharmacy Services for Wellmark Advantage Health Plan HMO: (TTY: 711)
- Pharmacy Services for Wellmark Advantage Health Plan PPO: (TTY: 711)
What if my prescription requires prior authorization?
First, you or your pharmacist should talk to your doctor as there may be another drug you can take that doesn't need prior authorization. If not, you can start the approval process by calling the number on the back of your Wellmark Advantage Health Plan ID card or by submitting a coverage determination form PDF File.
If you're a new Medicare Advantage member or there are changes to a prescription you're taking, you may need to transition to another drug.
This policy gives you time to work with us when:
- Your prescription isn't on your plan's drug list.
- Your prescription was taken off your plan's drug list.
- Your prescription requires approval or has restrictions it didn't before, like prior authorization or step therapy. (We'll send you and your doctor a letter if the status of your prescription has changed.)
How does the transition policy work?
If you just enrolled in your plan, your 90-day transition period begins when your coverage starts. If you are already a plan member, your 90-day transition period starts at the beginning of the plan year.
If you find that your plan doesn't cover a Part D prescription drug or it has added restrictions, during your 90-day transition period you can:
- Talk to your doctor about finding an alternative to the prescription that isn't on your plan's drug list.
- Go through any required approval process.
- Request an exception by submitting a coverage determination form PDF File.
During your 90-day transition period, we'll cover at least one filled prescription in most cases. It can be up to a month's supply from a retail or mail-order pharmacy in our network.
Long Term Care Setting
If you are a resident of a long-term care facility and need a drug that is not on our Drug List or is restricted in some way, the plan will cover a temporary one month’s supply of your drug during the first 90 days of your membership. The total supply will be for a maximum of a 31-day supply, or less if your prescription is written for fewer days. (Please note that the long-term care (LTC) pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
If you have been a member of the plan for more than 90 days and need a drug that is not on our Drug List or if the plan has any restriction on the drug's coverage, we will cover a 31-day emergency supply, or less if your prescription is written for fewer days.
If you have a level of care change, i.e. hospital to long-term care facility, we will cover a temporary 31 day transition supply (unless you have a prescription written for fewer days).
If you have more questions about our transition policy, call the Pharmacy Services number on the back of your Wellmark Advantage Health Plan ID card:
Call 24 hours a day, 7 days a week:
- Pharmacy Services for Wellmark Advantage Health Plan HMO: (TTY: 711)
- Pharmacy Services for Wellmark Advantage Health Plan PPO: (TTY: 711)
Keep in mind, in most cases, this prescription transition policy applies only to Part D prescription drugs purchased at a pharmacy in your plan's network. You can't use it to fill a prescription for a drug that Medicare doesn't cover.
The Wellmark Advantage Health Plan Medication Therapy Management (MTM) Program helps you get the most out of your medications by:
- Preventing or reducing drug-related risks
- Supporting good lifestyle habits
- Providing information for safe medication disposal options
Our Wellmark Advantage Health Plan offerings* for 2023 will feature the senior savings model for insulin products. This program features a broad set of formulary insulins and coverage throughout the initial coverage and coverage gap phases of the Part D drug coverage.
Important message about what you pay for insulin: You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on. A 90-day supply has a $105 copay.
*Excludes Blue Medicare Advantage Valor PPO plan.
