Pharmacy and prescription drug benefits

Your costs

Copays are a set dollar amount you pay for a covered service, like getting a prescription filled.

Medicaid members

Brand-name or generic drugs (including OTC medicine): $4 per script

Medicaid members in these groups do not have copay:

• Members under age 21
• Pregnant women
• Members receiving hospice care
• Federally recognized American Indians/Alaska Natives
• North Carolina Breast and Cervical Cancer Control Program (NC BCCCP) beneficiaries
• Children in foster care
• Disabled children under Family Opportunity Act
• People living in an institution who are receiving coverage for cost of care

There are no copays for certain medication classes including, but not limited to, approved family planning (birth control) medications, vaccines, diabetic testing supplies, and naloxone.

Prescription Drug Reimbursement Form

If you had to pay for a medicine that is covered under your plan, you may submit a request for reimbursement form.

Prescription Drug Reimbursement Form – English
Prescription Drug Reimbursement Form – Spanish

Drug coverage information

Your benefits include a wide range of prescription drugs. Healthy Blue also covers many over-the-counter (OTC) medicines with a prescription from your doctor. We have two drug lists that show which drugs are in your plan.

Preferred Drug List (PDL)

The Preferred Drug List (PDL) is the list of drugs that your doctor will use first when prescribing you medicine. These drugs have been chosen for their quality and effectiveness. Your doctor can prescribe most of these medicines to you without getting preauthorization, or an “OK,” from us. The PDL is updated frequently.

Don’t see it listed?

If you don’t see your medicine listed on the PDL, you may ask for an exception at submitmyexceptionreq@healthybluenc.com. You’ll be asked to supply a reason why it should be covered, such as an allergic reaction to a drug, etc.

Searchable formulary

The formulary is a list of all brand-name and generic drugs available in your plan. It lists all the drugs found on the PDL, plus others. All drugs on the formulary are covered, but many require preauthorization before the prescription can be filled.

Find your medicine

Do you want to look up your medicine and find out if it is covered in your plan? It’s easy when you use our search tool. This tool will help you learn about any limitations or restrictions for any particular drug.

You can search for your drug by:

• Typing the name (at least first three letters) of the drug in the search box
• Using the A-Z list to search by the first letter of your drug
• Clicking on the therapeutic class of the drug

Preauthorizations

Some medicines need a preauthorization, or an “OK,” from Healthy Blue before your provider can prescribe them. The preauthorization process helps us make sure that you’re taking medications safely and correctly.

Here are some reasons that preauthorization may be needed:

• There is a generic or pharmacy alternative drug available
• The drug could be misused or abused
• There are other drugs that should be tried first
• The drug has a high side effect potential
• The drug is prescribed at a higher dosage than recommended
• There is additional information needed about your condition so we can match it to the FDA approval of the drug and/or studies of effectiveness

For medicines that need preauthorization, your provider will need to call 1-844-594-5072. Healthy Blue will review the request and give a decision within 24 hours. If you need your medicine right away, you may be able to get a 72-hour supply while you wait.

Get your specialty medications

If you have a complex or chronic health condition that requires special medicine, you can get the medicine you need. We partner with CarelonRx Specialty Pharmacy and other providers to meet all your specialty medication needs.