BROUGHT TO YOU BY:
North Carolina Medical Society
Sentinel Benefits Consulting

Pharmacy Information

The NCMS Plan offers Pharmacy coverage through the medical plan. We partner with Blue Cross Blue Shield of North Carolina. BCBSNC acts as the NCMS Plan’s provider which means leveraging BCBS’ network, systems, and tools to administer our benefits. All Plans meet Essential Health Benefits (EHB) under the Affordable Care Act (ACA). We offer several Prescription Tier structures which vary based on plan.

Essential Formulary

All NCMS Plan health benefit offerings utilize the Essential C formulary through our partnership with BCBSNC and Prime Therapeutics. The formulary is a list of prescription medications covered by a health plan, which are reviewed on a quarterly basis by the Insurance Carrier regarding safety, effectiveness and current use in therapy that satisfy the priority health care needs of a population.

Online Medication Lookup

Results of the search will provide information on the medications coverage within the formulary including Tier Level. Members should use their BlueConnect accounts to get prices and in-network pharmacy details based on their benefits using the Find a Drug Search tool.

Pharmacy Tier Types

5 Tier Prescription Without Coinsurance

All tiers have a specified copay amount, this is the amount that you will pay per prescription in that tier.

Example: $10/$15/$35/$50/$100

Drug Tier

Type of Prescription

Cost

Tier 1
Least Expensive / Generic
$10
Tier 2
Higer priced generics / Lower priced brand-names
$15
Tier 3
Higher priced brand names
$35
Tier 4
Highest cost prescriptions
$50
Tier 5
Highest cost drugs including specialty drugs
$100

5 Tier Prescription With Coinsurance

All tiers have a specified copay amount, this is the amount that you will pay per prescription in that tier.
OR
Prescription costs are the member’s responsibility until the benefit period deductible has been met, then insurance pays 50% and member pays 50% of the cost. $100 prescription maximum for each 30-day supply on coinsurance tiers.

Example: $10/$15/$35/$50/50% (max $100)

Drug Tier

Type of Prescription

Cost

Tier 1
Least expensive / Generic
$10
Tier 2
Higer priced generics / Lower priced brand-names
$15
Tier 3
Higher priced brand names
$35
Tier 4
Highest cost prescriptions
$50
Tier 5
Highest cost drugs including specialty drugs
50%

Tier & Coinsurance Prescription

Tiers have either a specified copay amount, this is the amount that you will pay per prescription in that tier.
OR
Prescription costs are the member’s responsibility until the benefit period deductible has been met, then insurance pays 60% and member pays 40% of the cost. $100 prescription maximum for each 30-day supply on coinsurance tiers

Example: $10/60% (max $100)

Drug Tier

Type of Prescription

Cost

All Tiers
All levels of prescriptions
$10/60% after deductible (max $100)

Coinsurance Prescription

Prescription costs are the member’s responsibility until the benefit period deductible has been met, then insurance pays 90% and member pays 10% of the cost.

Example: 90% after deductible

Drug Tier

Type of Prescription

Cost

All Tiers
All levels of prescriptions
90% after deductible

Pharmacy Terminology

Term

Definition

Pharmacy

Facility that medicinal drugs are dispensed and sold.

Specialty Pharmacy

Facility licensed to dispense medications that are high-cost and used in the treatment of complex diseases.

Specialty Pharmacy List

List of pharmacies that are network participants with the chosen health plan.

Specialty Medication List

List of medications that are on the formulary for the treatment of complex diseases. Typically, these are oral, injectable, and infused medications.

HDHP Preventive Drug List

Specific to High Deductible Health Plan. List of medications available under the HSA Preventative Drug Coverage. Actual cost of medication is applied toward the preventative benefit, allowing coverage for medications even when the deductible is not met. Benefits are provided in accordance with the IRS guidance.

Mail Order Pharmacy

Online facility that dispenses non-specialty medicines written by your provider and delivered to your home.

Prior Authorization

Approval from insurance plan for a particular drug in order for the medication to qualify for coverage (completed prior to medication being dispensed).

Essential Drug Lists or Formularies

List of medications selected in regards to disease and public relevance, evidence of efficacy, safety, and comparative cost that satisfy the priority health care needs of a population.

Generic Drug

Medication created to be the same as an already marketed brand-name drug. Differences from name-brand: inactive ingredients such flavoring or preservatives may change, and generally costs less 

Brand-Name Drug

Medication sold under a specific name or trademark that is protected by a patent. Typically is more expensive than the generic version.

Covered After Deductible Prescription Structure

Medications are covered at a percentage after the deductible has been met. Typically, this structure is for High-Deductible Health Plans.

Diabetic Supplies, Space, and Flow Meters

Specific to maintaining, treating, and monitoring Diabetes. Coinsurance is applied.                         

Denial

Refusal by the insurance plan to pay for requested prescription. Common Reasons for Denials: refilling too soon, lack of prior-authorization (provider handles), out-of-network, drug utilization review (flagged as potential problem with prescription based on claims data, provider needs to handle directly).

Appeals

Member has the right to request a review of a denial/decision made by the insurance plan.

Mail Order (Amazon MedsYourWay)

The NCMS Plan’s integrated mail order pharmacy program is managed by Amazon MedsYourWay, a program included with all Medical Plan offerings. With Amazon MedsYourWay, you can order and ship non-speciality medications straight to your home. Mail order medications are often less expensive than traditional pharmacy medications and allow for larger quantities to be ordered for additional cost savings. MedsYourWay offers discounts on a variety of medications allowing members to choose based on discounted pricing or by applying their health plan co-pay. Costs for mail order prescriptions apply towards the health plan’s out-of-pocket maximum.

How To Get Started

OR

Call Amazon Pharmacy Customer Care for Blue Cross Blue Shield of North Carolina members.

Why Use Amazon MedsYourWay?