Drug Policies and programs
All Blue Medicare AdvantageSM HMO and PPO plans include prescription drug coverage at no extra cost.
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 formulary External Link or calling the Customer Service 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 (coming soon).
Many shoppers believe more expensive means better, but that's not always the case.
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 higher cost options if the lower cost option isn't suitable for you.
A step therapy plan would first treat a newly diagnosed condition with a cost-effective, biosimilar drug before progressing to a more costly drug therapy if the initial treatment was ineffective.
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 finding your drug on the drug formulary External Link, look for an ST after the name of your prescription. This signifies that the drug requires step therapy.
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 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 (coming soon).
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 formulary External Link and look for a PA after the name of your prescription.
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 (coming soon).
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 (coming soon). (Note: Generally, we give you a decision in less than 72 hours.)
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.
Our transition policy provides additional help if you are entering or leaving a long-term care facility or when you are discharged from the hospital, so you can get the medication you need while we work through the approval process.
For these circumstances, we'll:
- Cover multiple refills of your prescription during the 90-day transition period, up to a month's supply at a time.
- Cover a month's supply outside of the 90-day transition period in some situations.
If you have more questions about our transition policy, call the Customer Service number on the back of your Wellmark Advantage Health Plan ID card.
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.