Prescription Drugs and pharmacy benefits
Know if you have pharmacy coverage
If you have prescription drug coverage through Wellmark, this information can help you and your health care provider get the most from your prescription drug coverage. Find out if you have coverage through Wellmark in one of three ways:
- Log in and view your pharmacy coverage in myWellmark Secure Site®.
- Search for your coverage documents using your Wellmark ID number.
- Call the number on your Wellmark member ID card for assistance.
View your pharmacy coverage Secure Site
Log in to myWellmark to find an in-network pharmacy Secure Site.
Drug lists
Also known as a formulary, your drug list will tell you if a drug is covered under your plan, whether it needs special approval to be filled, coverage limits and if a generic option is available — which could save you money.
But first, you will need to know the name of your plan's drug list. Find out in one of these ways:
- Log in and view your Summary of Benefits & Coverage document Secure Site.
- Search for your coverage documents using your Wellmark ID number.
- Call the number on your Wellmark member ID card for assistance.
View your drug list:
- Blue Rx BasicSM External Site
- Blue Rx CompleteSM External Site
- Blue Rx EssentialsSM 2023 External Site
- Blue Rx PreferredSM External Site
- Blue Rx ValueSM External Site
- Blue Rx Value PlusSM External Site
- BlueSimplicitySM Rx External Site
Drug list (formulary) changes effective July 1, 2023 PDF File
PrudentRx Drug List PDF File
Important to know about drug lists:
- Your health plan’s drug list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market, so it’s good to check it regularly. For the most up-to-date information, log in to myWellmark Secure Site or call the number on your ID card.
- Your plan’s drug list will also show if it’s a specialty medication, if it has any prior authorizations, quantity or age limits, and what tier Glossary popover your drug falls on.
Find prior authorizations and quantity limits
For certain prescription drugs, additional coverage requirements or limits will apply. Prior authorizations encourage safe, cost-effective medication use by allowing coverage when certain conditions are met. myWellmark Secure Site will give you all the information you need to know to determine if your prescription is subject to prior authorizations and quantity limits.
In addition, coverage for certain drugs is limited to specific quantities per month, benefit year, or lifetime. The purpose of these quantity and dispensing limits is to improve the quality of pharmaceutical care to obtain appropriate outcomes and to address inappropriate utilization at the time of dispensing to minimize health risks and reduce overall costs. Requests for the drug to be filled over quantity limitations are not covered unless there is authorization criteria in place to request additional quantities from your health care provider and approval is granted.
Federal regulations limit the quantity that may be dispensed for certain medications. If your prescription is so regulated, it may not be available in the amount prescribed by your doctor. Your benefits certificate, coverage manual, or policy has specific information about your plan's authorization requirements.
Mail order pharmacy service
Depending on your pharmacy benefits, you may be able to save time and money by using mail order pharmacy for the prescriptions you take regularly. With mail order, filling your prescriptions is convenient, secure and confidential. The quickest way to get started is to log in to myWellmark, navigate to the Coverage page, click the Prescription tab, then Prescription Resources and Start Mail-Order Service. There you will be directed to Wellmark’s preferred pharmacy vendor to complete registration.
Note: For specialty drugs, use one of our preferred vendors.
Start mail order pharmacy Secure Site
Don't have a myWellmark account? No problem. Create a Caremark.com External Site account using your Wellmark ID and personal information to fill prescriptions and manage your order pharmacy account.
Pharmacy exception requests
If you need to request the review of a coverage determination for a drug, you can work with your provider to submit an exception request for coverage. Your provider will need to explain the medical reasons why you need the exception approved. These exceptions include:
- Non-formulary drug exception: A request to cover a non-formulary drug that is not included on your plan’s drug list.
- Brand penalty exception: A request to receive a brand-name drug instead of a generic alternative and pay only the appropriate brand cost-share.
- Contraceptive zero copay exception: A request to cover a contraceptive as a preventive service and pay $0.
Once the exception request review is completed, a letter will be sent to you and your provider will be notified of the decision by mail or fax.
For more information on exception requests and how you and your doctor can request an exception, see your coverage manual, contact Wellmark Customer Service at the number on the back of your ID card, or reference the Pharmacy forms for providers.
