Blue Cross of Georgia May Empty Your Wallet

If you have a Georgia health insurance policy through Blue Cross (BCBSGA), you may be in for an unwelcome surprise. Some of their plans may not cover your brand name drug.

I discovered this quite by accident while helping a friend navigate her new BCBSGA health insurance policy purchased through Blue Cross direct (no agent involved). She is a bit overweight and takes medication to control high blood pressure and cholesterol. In applying for coverage she did ask if her medications would be covered.

The rep indicated that two of the three medications were not on their formulary, but that is as far as they went.

Her husband contacted me for advice and we went looking for a plan that would cover all of her medications. I found two plans that included all three med’s and after further review, we picked one that was a better fit.

She applied for coverage through Georgia Insurance Shop and everything went fine until the underwriting phone interview. During the recorded interview she revealed that she had lost weight over the last 12 months. The weight listed on her application was right on the border for a potential decline so the health insurance company did the responsible thing and requested medical records.

As it turns out her last recorded weight was higher than listed, and her weight from a year ago even higher. The combination of these factors, plus the medications resulted in her application being denied.

So why did Blue Cross accept her and this carrier did not?

Blue failed to conduct a thorough investigation on the front end. And yes, this can come back to haunt her in more ways than one.

Her husband asked for suggestions to save money on the cost of medication, so I linked him to some mailorder Rx sites. I told him to have his wife call Blue Cross (I can’t do it since I am not her agent) and ask how much these non-formulary drugs will cost under her Blue Cross plan.

The response . . . full retail and she cannot use their mailorder facility. Not only that, but since they are not covered there is no deductible credit either.

That was a shock.

It is not unusual to find that your medication may not be on a formulary, but very unusual to discover the drug is not covered under any circumstances.

So this lady is in a bit of a pickle . . . and so is everyone else who bought this plan.

The med’s she takes that are not covered are relatively inexpensive . . . less than $200 at retail. So what happens if she develops a new condition that requires her to take an expensive medication that falls outside their formulary?

Not covered.

No copays, no discounts, no deductible credit.

That’s a real bummer.

So how do you find out if a medication is covered under a formulary?

Well you have to ask. But if you fail to ask the right question you may not get the answer you need.

How do you find out what is covered on the BCBSGA formulary?

Buy a policy, then go to their website or call customer service. Even if you are dealing with an agent, that agent will not be able to tell you unless he/she is also a Blue Cross policyholder.

If you have bought a Blue Cross of Georgia individual major medical policy in the last two years, you need to ask them if non-formulary drugs are covered under your plan. If not, you need to make a change right now if you can.

I have been in this business for more than 35 years and have never run across a provision like this that is so well hidden you will never find out until it is too late. This has prompted me to pose a direct question to other health insurance companies I represent and ask how their plan treats non-formulary drugs.

If you are looking for affordable health insurance in Georgia, be very careful and don’t be afraid to ask questions.


  1. Good points here, to ask questions and BE SPECIFIC! This is a great way to remind people WHY they need a great agent to start with. However, having worked for said carrier, there are few plans that don’t at least offer the carrier discount on even noncovered, name-brand RXs. I think she should call & push for more details on that matter.

    With that being said, please don’t put the misnomer out there that just becuase someone has the same carrier’s coverage as you, that they should know what your formulary is. Within one company, there are numerous different plans with oodles of levels of benefits. Never, ever trust what someone else says is covered under their plan as a way of finding out what YOUR plan covers. Let me know if I can help you navigate these waters in any way!

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