Prescription drug costs

Prescription drug costs can vary widely, even for medications that treat the same condition. Many people assume the lowest-cost medication is always the best option, but prescription drug costs can be influenced by several factors.

• Type of drug
• Your health plan's coverage
• Your formulary
• The drug's tier

Understanding how prescription drug coverage works can help you make informed decisions about your medications and identify opportunities to save money.

Most healthy people who have insurance, including Blue Cross and Blue Shield of North Carolina (Blue Cross NC) members, have a drug plan that covers prescriptions from the pharmacy. If you're taking medications or will be soon, it's important to understand how drug costs work and where you might save money.  There are three different drug categories: brand-name, generic, and specialty.

Your health plan includes a list of covered medicines called a formulary. Within your formulary, medications are put into categories called tiers.

Your prescription drugs could be in one of the four-tier, five-tier, or six-tier formularies. These tiers are based on drug usage, cost, and clinical effectiveness. This helps determine how much you may have to pay for your medicine.

While generic drugs are often the most affordable option, the lowest-cost choice will depend on your health plan's formulary and tier placement. In some cases, a brand-name drug may be covered at a similar cost to a generic one.

If you're a Blue Cross NC member, you can use our Find Care tool to search for a drug within your specific formulary.

Preventive drugs¹ are drugs that help prevent disease or other health conditions – think vaccines to prevent flu or iron supplements to prevent iron deficiency anemia.

Most health plans, including Blue Cross NC plans, have an Affordable Care Act preventive drug benefit. This means these medications are available to you at no additional cost or at a reduced cost.

In addition to preventive drugs, which are covered under all prescription drug plans, some plans with Health Savings Accounts (HSAs)² provide additional preventive coverage of drugs for certain chronic conditions.

The HSA preventive benefit enhancement is available on specific high-deductible health plans. This benefit waives the deductible for preventive drugs for certain chronic conditions.

If there's a medical reason you need a brand-name medication, have your provider follow the steps to get prior authorization for brand-name prescription drugs.

If you are a Blue Cross NC member, all the information your provider needs can be found on our Provider's Prior Authorization for Prescription Drugs page, including any forms they may need to fill out and submit.

Medications not included in your formulary are called non-formulary drugs. If your doctor prescribes a medication that isn’t covered on your formulary, he or she will have to fill out a form to request a non-formulary medicine for you.