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Medicare

Policies, privacy, and legal

Learn more about your rights and responsibilities as a Medicare member, our quality assurance practices, how to appeal a coverage decision or determination, and how you are covered in a disaster.
General information

In the event of a declared emergency or disaster in our service area by the President of the United States (national emergency), the governor (emergency), or Secretary of Health and Human Services (public health emergency), Blue Cross and Blue Shield North Carolina (Blue Cross NC) will cover some plan benefits.

Medical coverage

Blue Cross NC will cover Medicare Parts A, B, and supplemental Medicare Advantage plan benefits at non-network hospitals and other medical facilities.

Members will not need a referral from their primary care provider (PCP) for treatment. If a provider accepts Medicare or is a Medicare-certified facility, we will cover the service. This includes dialysis services.

Members will pay in-network cost sharing even if they use out-of-network providers.

Prescription drug coverage

Blue Cross NC will temporarily allow affected members to get an early refill of their medications and maximum extended-day supplies from in-network pharmacy providers, nationwide.

Members who use out-of-network pharmacies may not have prescription coverage. If you can’t access your usual network pharmacy, call us at the number on the back of your member ID card. Our Customer Service team will help you find a network pharmacy to use. If there is not a network pharmacy reasonably available for you to use, you will be able to use an out-of-network pharmacy. However, the cost for your prescription drugs may be higher.

Access to health care

A declaration of a disaster or emergency will identify the geographic area affected. Blue Cross NC will take immediate action when either the Secretary of Health and Human Services declares a public health emergency, or a governor or the U.S. President declares a disaster or other type of emergency and we have determined that there is a disruption in access to health care.

We work fast to help members during a state of emergency or disaster declaration. When it is in members’ best interest for us to do so, we will not wait for the usual 30 days’ required notice to make these changes.

For medical coverage, we will offer this support for 30 days after the earlier of the following conditions:

  • The emergency or disaster has ended as defined by regulatory requirements, or
  • There is no longer a disruption of access to health care.

For prescription drug coverage:

  • We will continue to lift these restrictions until the end of the declared disaster or emergency.

Impact to offices

If the disaster or state of emergency affects the offices of Blue Cross NC and we cannot resume operations by the end of the disaster or emergency, we will notify the Centers for Medicare & Medicaid Services (CMS). We will also update our Blue Cross NC website with information about our business activities and hours of operation as soon as we are able to do so.

Keeping you updated

We will keep you updated with important information online. Visit bluecrossnc.com for the latest information about using your health or prescription drug benefits during a disaster or state of emergency.

If your coverage with Blue Cross NC has ended and you need proof of coverage, please call the Customer Service number on the back of your Blue Cross NC member ID card. If your coverage is still active, and you need a Certification of Health Insurance Coverage document, please call the Customer Service number on the back of your Blue Cross NC member ID card.

Rights and responsibilities

As a member of our plan, you have certain rights on how you can expect to be treated by us, and your responsibilities when seeking care.

Learn More
Medicare Advantage and Prescription Drug Plan information

Some legal and policy information is specific to members of Medicare Advantage and Prescription Drug Plans. 

Medical coverage decisions, appeals, and grievances

Prescription drug coverage determinations, appeals, and grievances

Blue Cross NC, has a contract with the Centers for Medicare & Medicaid Services (CMS) to provide a Medicare Advantage prescription drug plan (MAPD). Blue Cross NC is also a Medicare-approved Part D sponsor. CMS is the government agency that runs Medicare. This contract renews each calendar year. Each year the contract is reviewed, and either Blue Cross NC or CMS can decide to end it. Members will get 90 days advance, written notice if the contract will not be renewed in this situation. It is also possible for our contract to end at some other time. If the contract is going to end, we will generally tell members 90 days in advance. Advance notice may be as little as 30 days or even fewer days if CMS ends our contract in the middle of the year. In this notice, we would provide a written description of alternatives available for obtaining qualified prescription drug coverage in North Carolina. We are also required to notify the general public of a contract termination via local newspapers.

If Blue Cross NC decides to stop offering Blue Medicare HMO-POS℠, Blue Medicare PPO℠ or Blue Medicare Rx℠ coverage, or change the service area so that it no longer includes the area where you live, membership in Blue Medicare HMO-POS, Blue Medicare PPO or Blue Medicare Rx affected by that change will end for everyone in the affected plan within that service area, and members will have to change to a different Medicare Advantage or Medicare drug plan, return to Original Medicare or select a Medicare Supplement plan, if needed. Blue Medicare HMO-POS, Blue Medicare PPO or Blue Medicare Rx will provide coverage until the contract ends.

Quality assurance includes the processes and systems put in place to evaluate prescriptions for health and safety issues. They help promote the appropriate use of medications by improving compliance and reducing medication errors and adverse drug interactions.

Quality assurance processes for Blue Medicare HMO℠, Blue Medicare PPO℠ and Blue Medicare Rx℠ PDP are summarized below:

Concurrent Drug Utilization Review (cDUR)

This occurs while a claim is being processed at the pharmacy. Prescriptions are screened for safety issues and the pharmacist is sent a message immediately, alerting them of the potential issue. Below are some examples of cDUR:

  • Drug Interactions: Instances when the prescribed drug can potentially result in ineffective or unsafe treatment when used in combination with another drug.
  • Drug-Allergy: Identifies when the prescribed drug may potentially cause problems based on patient's reported allergies.
  • Drug-Disease: Instances when the prescribed drug may potentially worsen the patient's reported medical condition(s).
  • Drug-Gender Contraindications: Identifies prescription medications being inappropriately filled based on patient gender.
  • Drug-Age: Identifies those drugs that are contraindicated for use by older adults.
  • Excessive Daily Dosing and Duration of Therapy: Identifies when a prescription claim is being filled for more than the recommended maximum daily dose or duration.
  • Refill Too Soon or Too Late: Identifies patients who may not be taking their medication as prescribed by their physician, and are requesting a refill too soon or too late based on the date and quantity of the last fill.
  • Therapy Duplication: Identifies when the prescription being filled is from the same therapeutic class as other medications in the members profile.
  • Potential Drug Name Confusion: Identifies prescriptions that sound alike, or when written, look alike.

Retrospective Drug Utilization Review (rDUR)

This occurs after the prescription has been dispensed. It is a program that evaluates a member's drug history to identify prescribing issues. Alerts are provided by mail to physicians, addressing prescribing practices and uses that are unsafe, ineffective, or otherwise inconsistent with evidence-based standards of care. Retrospective DUR complements the Concurrent DUR program. 

The Retrospective DUR health and safety alerts are made up of four key categories:

  • Potential Drug-Drug Interactions: Instances when prescribed medications can potentially result in ineffective or unsafe treatment when used in combination with another drug.
  • Dose Considerations with Pain Medications: Examines the use of certain high dose pain medications.
  • Drug Age Considerations: Considers the adverse effects of certain drugs or drug classes on the elderly population.
  • Therapy Duplication: Identifies the use of two or more drugs in the same therapeutic class that may put the patient at risk of additional unwanted side effects or a medical emergency.

Refill reminders to patients

As part of the prescription dispensing process, reminders to refill prescriptions can be sent to members via email, text, or phone call. These reminders help members to continue taking their medications as prescribed.