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Medical Benefit Drug Coverage

Some prescription drugs can be taken on your own. These are often covered under your pharmacy benefits. Other prescription drugs are given by a provider, like a doctor or nurse, in a clinic, hospital, or office. These drugs may be covered under your medical benefits rather than your pharmacy benefits.

Starting 9/1/2026, medical coverage for certain medications may require you to:

  • complete step therapy
  • get treatment at an approved site of care

These coverage requirements are outlined in your TRS-ActiveCare plan. Call 1-866-355-5999 or chat with a Personal Health Guide in the BCBSTX App or review your certificado de beneficios y servicios médicos para ver más detalles.

Drug lists may change frequently. Get the latest information below.

Coverage Requirements and Affected Drug Lists

Terapia escalonada

Step therapy means you may need to try one or more drugs before another drug is covered. It’s part of your TRS-ActiveCare plan design, not a medical decision about what you need. Your coverage may depend on completing the steps.

Review the list of Medical Benefit Drugs with a Step Therapy Requirement para obtener más detalles.

Site of Care

Some medications covered under your TRS-ActiveCare plan have site of care requirements. These medications are usually given by infusion or injection. Site of care defines where a medication is given, not if it’s appropriate for your treatment.

Coverage for these drugs is usually available in lower-cost outpatient settings, such as:

  • provider’s office
  • specialty clinic
  • freestanding infusion center
  • home infusion (when available)

You may pay more if the drug is given at a non-preferred location. Hospital outpatient settings may not be covered for some medications unless you get an exception. If a hospital setting is approved, it only applies to where the drug is given, not if the drug is covered.

Consulte el Site of Care Drug List para obtener más detalles.

What if Your Medication is on the List?

  • These requirements are health plan coverage rules. They don't determine coverage of the medication itself. Your provider may need to request a prior authorization, or pre-approval, for coverage of the medication.
  • Talk to your provider about your treatment options.
  • Your provider can ask for an exception by completing one of these forms:

¿Tiene alguna pregunta?

For more information about medical benefit drugs, coverage limitations or your benefits, call a Personal Health Guide at 1-866-355-5999 or chat through the BCBSTX App.