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Prime Therapeutics, LLC, is an independent pharmacy benefit manager for Blue Cross and Blue Shield of Alabama. This section only applies to you if Prime administers your patient’s pharmacy benefits.

Drugs are selected for the prescription drug guides based on the recommendations of a committee of physicians and pharmacists from throughout the country. The committee, which includes representation from Blue Cross, reviews drugs regulated by the U.S. Food and Drug Administration (FDA).

The prescription drug lists are updated each quarter and posted on our website, AlabamaBlue.com/DrugList. The quarterly updates to the prescription drug lists are posted to the website prior to the effective date of the changes. Negatively impacted members and providers 
are notified.

Blue Cross typically groups drugs into one of the following four or six tier levels based on specific member benefits:

• Tier 1 - primarily generics and select brands
• Tier 2 - primarily preferred brands
• Tier 3 - primarily non-preferred brands
• Tier 4 - primarily specialty (if applicable)

OR

• Tier 1 - primarily preferred generics
• Tier 2 - primarily non-preferred generics
• Tier 3 - primarily preferred brands
• Tier 4 - primarily non-preferred brands
• Tier 5 - primarily preferred specialty
• Tier 6 - primarily non-preferred specialty

Tier 1 drugs have the lowest cost to the member while Tiers 4–6 drugs have the highest cost to the member. Coverage and member costs vary based on the plan. Drugs that require prior authorization, step therapy or have dispensing limits are noted in the prescription drug lists. If you cannot locate your patient’s applicable drug list, please contact a Customer Service Representative for assistance identifying the appropriate drug list. Once identified, visit AlabamaBlue.com/DrugList, choose Prescription Drug Guides, and select the drug list identified by the Customer Service Representative.

Prescription drugs are classified as either a brand drug or a generic drug. Blue Cross uses the brand or generic status given by a nationally recognized company providing drug product information. The brand/generic status of a drug can sometimes change over the life of the drug and can change from brand to generic or from generic to brand. These changes may alter the amount the member pays for the drug. The brand or generic status of a drug is never based on a product having a trade name. Generic drugs often have trade names.

Blue Cross encourages utilization of generic medications as a way to provide high-quality drugs at a reduced cost. Generic drugs are as safe and effective as their brand counterparts, but are usually less expensive. Generic drugs are manufactured under the same strict requirements of the FDA’s current Good Manufacturing Practice regulations required for brand drugs and cover the manufacturing, identity, strength, purity and quality.

An FDA-approved generic drug may be substituted for the brand counterpart when it:

• Contains the same active ingredient(s) as the brand drug;
• Is identical in strength, dosage form and route of administration; and
• Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile.

Call our Customer Service Department to verify if the medicine is covered. If it is not, a Customer Service Representative can assist you in requesting coverage of the noncovered drug or in completing the “General Prescription Drug Authorization Request Form.”

To request a formulary exception to our coverage rules, use the General Prescription Drug Coverage Authorization request form. 

Provider-Administered Drugs
Provider-administered drugs require that a member’s medical condition meets the policy requirements prior to being given (precertification). Providers must submit a request for pre-service review in order to be approved. If the provider does not receive approval for precertification, the plan will pay no benefits.

Precertification through Magellan Rx is required for the provider-administered drugs on the Provider-Administered Precertification Drug List when administered in a provider’s office, outpatient facility or home health setting; precertification does not apply to inpatient hospital claims at this time.

View the Provider-Administered Drug Policies webpage to view more information on these drugs, as well as provider-administered specialty drugs.

Prime Therapeutics^® LLC, is an independent company contracted by Blue Cross and Blue Shield of Alabama to provide pharmacy benefit management services.

Magellan Rx Management^SM is an independent company providing medical review services on behalf of Blue Cross and Blue Shield of Alabama.