Prescription drug resources

The list of drugs covered on each plan, along with any restrictions for those drugs, can be found in the formulary guides below.

2023 formulary guides

• Blue Medicare Choice (PDF)
• Blue Medicare Enhanced (PDF)
• Blue Medicare Essential (PDF)
• Blue Medicare Essential Plus (PDF)
• Blue Medicare PPO Enhanced (PDF)
• Blue Medicare Rx Enhanced (PDF)
• Blue Medicare Rx Standard (PDF)
• Blue Medicare HMO EGWP MAPD (PDF)
• Blue Medicare HMO EGWP MAPD (plans with deductible) (PDF)
• Blue Medicare PPO EGWP MAPD (PDF)
• Blue Medicare Rx EGWP HCE (PDF)
• Blue Medicare PPO EGWP Complete (PDF)
• Blue Medicare Rx EGWP Complete (PDF)
• Healthy Blue + Medicare (HMO D-SNP) (PDF)

Pharmacy directory

• 2023 Blue Medicare HMO, PPO, and Rx (PDF)

Members with Blue Medicare Choice, Blue Medicare Essential, Blue Medicare Essential Plus, Blue Medicare Enhanced, Blue Medicare PPO Enhanced, and Healthy Blue + Medicare can take advantage of $0 copay drugs at preferred retail pharmacies and Express Scripts, AllianceRx Walgreens Pharmacy, or Postal Prescription Services (PPS) mail-order pharmacies during the deductible, initial coverage and coverage gap phases or a low copay at standard pharmacies. The Formulary Tier 6 Select Care drug list below includes a wide range of commonly prescribed generic drugs used for high blood pressure, high cholesterol, diabetes, osteoporosis, and rheumatoid arthritis. Talk with your doctor to determine if a Formulary Tier 6 Select Care drug is appropriate to treat your condition so that you get the best value from your pharmacy benefits.

2023 Formulary Tier 6 Select Care Drugs (PDF)

The Blue Cross NC mail order prescription program offers you the convenience of receiving up to a 90-day supply of medication delivered to you with free standard day shipping. Typically, you should expect to receive your prescription drugs within five to fourteen days (using standard shipping) from the time that the mail order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact us at the phone number listed on the back of your member ID card.

Medicare Advantage Prescription Drug (MAPD) plans and Prescription Drug Plans (PDP) members with pharmacy benefit coverage through Blue Cross NC will be able to use the following mail order pharmacies:

Preferred mail order pharmacies (where you’ll experience the most cost savings):

• AllianceRx Walgreens Pharmacy (ARxWP) (PDF)
• Express Scripts Pharmacy (ESI) (PDF)
• Postal Prescription Services (PPS) (PDF)

Standard mail order pharmacy:

• Costco Mail Order Pharmacy (PDF)

What you get

With our pharmacy mail order vendors, you get the convenience of having your maintenance medications delivered right to your door plus many other features.

• Simple, stress-free ordering
• Safe, accurate prescriptions delivered to your door
• World-class customer support
• Free standard delivery in weather-proof packaging
• Specially trained pharmacists ready to answer your questions 24/7
• Affordable medication prices based on your benefit plan

You should continue to get your short-term prescriptions, such as antibiotics, from your local pharmacy where you may pay less if you only need a one-month supply.

Getting started

Sign in to Prime Therapeutics and find medicines available for mail order.

Step 1: Register

There are three convenient options.

• Online - Register online by going to AllianceRx Walgreens Pharmacy, Express Scripts Pharmacy, Postal Prescription Services (PPS)  or Costco Mail Order Pharmacy.
• Telephone - Call AllianceRx Walgreens Pharmacy (ARxWP) at 877-277-5457, Express Scripts Pharmacy (ESI) at 833-599-0450, Postal Prescription Services (PPS) at 800-552-6694 or Costco Mail Order Pharmacy at 800-607-6861, and a Customer Service Representative will help get you started. TTY users call 711.
• Complete and mail the prescription order form. See Step 2 below.

Step 2: Send in your prescription

Once you are registered, the mail order pharmacy will need your prescription. You can have your doctor submit it by phone, fax, or electronically, or you can mail your prescription with a completed form and your proper copayment.

• AllianceRx Walgreens Pharmacy (ARxWP): To start an order for prescription drugs or refills, fill out the AllianceRx Walgreens Pharmacy order form (PDF), download an order form and mail to: 

AllianceRx Walgreens Pharmacy (ARxWP)
P.O. Box 29061
Phoenix, AZ 85038-9061

• Express Scripts Pharmacy (ESI): To start an order for prescription drugs or refills, fill out the Express Scripts Pharmacy order form (PDF), download an order form and mail to:

Express Scripts Pharmacy (ESI)
Home Delivery Service
P.O. Box 66577
St. Louis, MO 63166-9838

• Postal Prescription Services (PPS): To start an order for prescription drugs or refills, fill out the Postal Prescription Services (PPS) order form (PDF) and mail to:

Postal Prescription Services
P.O. Box 2718
Portland, OR 97208-2718

• Costco Mail Order Pharmacy: To start an order for prescription drugs or refills, fill out the Costco Mail Order Pharmacy order form (PDF) and mail to:

Costco Mail Order Pharmacy
802 134th St. SW, Suite 140
Everett, WA 98204-9935

Prior authorization

Prior Authorization is a program that requires members to meet certain criteria prior to a drug being covered. It may be used to encourage the appropriate use of prescribed drugs based on the U.S. Food and Drug Administration (FDA) approved labeling and other medical literature. Please see the member's formulary for drugs that require review.

2023 Prior Authorization Criteria

• Blue Medicare Rx Standard (PDF)
• Blue Medicare Rx Enhanced (PDF)
• Blue Medicare PPO Employer Group Complete, Blue Medicare Rx Employer Group Complete, Blue Medicare HMO Employer Group Complete (PDF)
• Blue Medicare HMO Employer Group MAPD, Blue Medicare PPO Employer Group MAPD (PDF)
• Blue Medicare Rx Employer Group HCE (PDF)
• Blue Medicare Choice, Blue Medicare Enhanced, Blue Medicare Essential, Blue Medicare Essential Plus, Blue Medicare PPO Enhanced (PDF)

Step therapy

Step therapy is a program that requires members to first try one drug to treat their condition before Blue Cross NC will cover another drug for that condition. Please see the member's formulary  for drugs that require review

2023 step therapy criteria

• Blue Medicare Rx Standard (PDF)
• Blue Medicare Rx Enhanced (PDF)
• Blue Medicare PPO Employer Group Complete, Blue Medicare Rx Employer Group Complete, Blue Medicare HMO Employer Group Complete (PDF)
• Blue Medicare HMO Employer Group MAPD, Blue Medicare PPO Employer Group MAPD (PDF)
• Blue Medicare Rx Employer Group HCE (PDF)
• Blue Medicare Choice, Blue Medicare Enhanced, Blue Medicare Essential, Blue Medicare Essential Plus, Blue Medicare PPO Enhanced (PDF)

Certain drugs have a designated quantity that will be covered. These limits are designed to identify the excessive use of drugs which may be harmful in large quantities, to highlight the potential need for a different type of treatment, and to match dosing recommendations / requirements set by the manufacturer and the FDA. For some of these drugs, if the provider feels it is medically necessary to exceed the set limit, he/she must request prior approval before the higher quantity can be covered. Quantity Limitations are listed in the formulary guides. Requests can be submitted to Blue Cross NC using the Quantity Limit fax form below.

• Quantity Limit Exception Criteria Form (PDF)
• Quantity Limit Fax Form (PDF)

The necessary information to process a request for drugs not covered on the formulary is outlined in the criteria below. Please be advised that incomplete forms may delay processing.

• Non-formulary Exception criteria (PDF)
• Non-formulary Exception fax form (PDF)

The necessary information to process a request that a drug be covered at a lower copayment level is outlined in the criteria below. Note that request for  Tier Exceptions may not be requested for drugs in Tier 5 Specialty. Please be advised that incomplete forms may delay processing.

• Tier Exception criteria (PDF)
• Tier Exception fax form (PDF)

There are some situations when certain drugs are covered under Medicare Part B. See the CMS Coverage database for Medicare Part B drug coverage clarification.

If these drugs are not eligible for coverage under Medicare Part B, they may be covered under Medicare Part D with prior approval by the plan. These requests should be submitted on the Medicare Part B vs Part D fax form below.

• Medicare Part B vs Part D fax form (PDF)

There are some drugs that require Step Therapy and/ or Prior Authorization under Medicare Part B.

Part B Step Therapy is a program that requires members to first try a safe, effective, lower-cost drug to treat their condition before Blue Cross NC will cover another drug for that condition. Please see the Drug List below for those drugs requiring Step Therapy under Medicare Part B.

Part B Prior Authorization is a review of the medical drug prior to administration to determine if the drug is eligible for coverage by Blue Cross NC. Coverage determinations will be made in accordance with guidelines set forth by the Centers for Medicare & Medicaid Services (CMS), including National Coverage Determinations (NDCs), Local Coverage Determinations (LCDs), and medically accepted indications.

These requests should be submitted on the appropriate Medicare Part B Prior Authorization or Part B Step Therapy fax form. Drug-specific fax forms and criteria can be found in the Drug Search box under the Prior Authorization and Step Therapy section of this webpage.

• Medicare Part B Step Therapy and Prior Authorization Drug List (PDF)

Blue Cross NC is responsible to make sure all drugs covered under Part D are prescribed for medically-accepted indications, and that each prescription drug has a drug product national drug code properly listed with the Food and Drug Administration.

You can access the member's formulary for detailed information regarding covered drugs and drugs requiring review by Blue Cross NC.

Members may contact Customer Service at Blue Cross NC in order to request a drug. All requests require a physician's supporting statement before the drug can be considered for payment. 

The member's prescribing provider may initiate a request with the plan in one of the following ways:

• Electronic request (preferred): We have teamed with CoverMyMeds to offer electronic review submissions.
• Fax: Faxes can be sent to the fax number on the bottom of your form.
• By phone: Call the number for your plan. After normal business hours, messages can be left on the Medicare Part D After-Hours Exception voicemail.

Compound drug requests

Compounded drugs require review for consideration of payment. As a whole, compounded drugs do not satisfy the definition of a Medicare Part D drug, as outlined in Chapter 6 of the Medicare Prescription Drug Manual (Section 10.4). Therefore, each individual ingredient of a compounded drug must be reviewed. Please note, bulk powders do not satisfy the definition of a Medicare Part D drug and are not covered by Medicare Part D. Requests for coverage of a compounded drug should be submitted on the Compounded Drugs fax form below.

• Compounded Drugs fax form (PDF)

Hospice drug requests

The form below contains the necessary information for requests of coverage for prescription drugs under Medicare Part D when the member is in Hospice care, and it is believed the drugs should not be covered under the Medicare Part A hospice benefit.

• Hospice fax form (PDF)

Blue Cross NC only covers two brands of diabetes test strips for MAPD members: Lifescan (OneTouch) and Ascensia (Contour). All other test strips are not covered. The member can switch to a covered diabetes test strip and receive a compatible new meter at no cost to them.

All diabetes test strips must be filled at a network retail or mail order pharmacy. Test strips can no longer be filled through durable medical equipment (DME) suppliers. 

Diabetes test strips have a designated quantity that will be covered. These limits are designed to match blood sugar testing recommendations. If the provider feels it is medically necessary to exceed the set limit, he/she must request prior approval before the higher quantity can be covered.

Covered Continuous Glucose Monitors (CGMs) obtained through the pharmacy are Dexcom G6 and Abbott Freestyle Libre.

Blue Cross NC will allow non-covered diabetes testing supplies and quantity limit exceptions to be approved. These requests should be submitted on the appropriate Diabetes Testing Supplies fax form. The necessary information to process a request for Diabetes Testing Supplies not covered and quantity limit exceptions is outlined in the criteria below.

• Test Strips and Meters Fax Form (PDF)
• Test Strips and Meters Prior Authorization Criteria (PDF)
• Continuous Glucose Monitor Fax Form (PDF)
• Continuous Glucose Monitor Prior Authorization Criteria (PDF)

If you are affected by a change in which your drugs are removed from the formulary1 (no longer covered), or in which your drugs are moved to a tier requiring a higher member copayment, Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx will mail you a notification. This notification will be sent at least 30 days before the formulary change will take effect. The plan will tell you why the change is being made and will list alternative drugs with expected costs.

You are encouraged to use this 30-day time frame to have your drug switched to an appropriate alternative medication. You also have the option to ask Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx for a coverage exception.

Please note: Notification about drugs that are removed from the market due to safety reasons or due to the plan's determination that they are non-Part D drugs will not be sent within 30 days of removal from the market.

This policy describes the transition requirements published by the Centers for Medicare and Medicaid Services (CMS) which state that all Part D sponsors must provide an appropriate transition benefit for members. For questions about this policy please call the phone number on the back of your Member ID card.

This policy covers the following:

• Eligible members
• Applicable drugs
• New prescriptions versus ongoing drug therapy
• Transition time frames
• Transition extensions
• Transition across contract years for current members
• Emergency supply for current members
• Treatment of re-enrolled members
• Level of care changes
• Transition notices

This policy describes how transition benefits apply when you are filling prescriptions in:

• Long Term Care (LTC) settings
• Retail pharmacies
• Extended Supply Network (ESN) (90 days of retail setting)
• Mail Order pharmacies

Eligible members

If you are currently taking drugs that are not included in your plan's new formulary1 (drug list) from one year to the next, you may be eligible for a transition supply if you are:

• New to the prescription drug plan at the start of 2023
• Newly eligible for Medicare Part D in 2023
• Switching from one Medicare Part D plan to another after January 1st, 2023
• Affected by negative changes to the plan's drug list from 2022 to 2023
• Living in an LTC setting

Applicable drugs

The transition benefits allow members to receive a supply of eligible Part D drugs when the drugs are:

• Not on your plan's list
• Previously approved for coverage under an exception once the exception expires
• On your plan's drug list but your ability to get the drug is limited. For example, under a Utilization Management (UM) program that require:
  • Prior Authorization (PA)
  • Step Therapy (ST)
  • Quantity Limits (QL)

You may be eligible for a transition supply of a drug in order to meet your immediate needs. This is meant to allow enough time for you to work with your doctor to find a similar drug on the plan's drug list that will meet your medical needs or to complete a coverage determination to continue coverage of a drug you are currently taking based on medical necessity. An approved coverage determination request may allow continued coverage of a drug you are currently taking.

Certain drugs may not be eligible for a transition supply at the pharmacy; these drugs first require a review to determine if they can be covered by your Part D plan.

If you or your doctor want to request a coverage determination, the forms are available by mail, fax, email, and on our website; you can access the forms yourself or request a form be sent to you and/or your doctor. The plan reviews coverage determination requests and will notify you once a decision is made. If the plan does not approve the request, you will be provided with additional information regarding your options.

You may qualify for refills of transition supplies that are dispensed for less than the written amount due to quantity limits, which may be used for safety purposes.

New prescriptions versus ongoing drug therapy

Transition benefits are applied at the pharmacy to new prescriptions when it is not clear if a prescription is for a drug you are taking for the first time or an ongoing prescription for a drug that is not on your plan's drug list.

Transition time frames

In outpatient settings (retail, ESN and mail order)

If you are new or re-enrolled to the plan, you may be allowed a 30-day transition supply of eligible Part D drugs (unless the prescription is written for a fewer days) any time during your first 90 days of coverage.

In LTC settings

You may be allowed a 31-day transition supply (unless the prescription is written for fewer days) of eligible Part D drugs during the first 90 days of coverage. After the 90-day transition period has ended, if a coverage determination request is being processed you may be able get an emergency 31-day supply.

Transition extension

The transition period may be extended on a case-by-case basis if the review of a coverage determination request or an appeal has not been processed by the end of your minimum transition period (first 90 days of coverage). The extension is then provided only until you have switched to a drug on the plan's drug list or a decision on the coverage determination request or appeal is made.

Transition across contract years for current members

If you have not switched to a covered drug prior to the new calendar year, a transition supply may be provided if the following has occurred:

• Your drugs are removed from the plan's drug list from 2022 to 2023
• New UM requirements are added to your drugs from 2022 to 2023

If you are an existing member with recent history of using a drug which is not covered by your plan or you have limited ability to get the drug:

• In a retail setting you may get a 30-day transition supply (unless the prescription is written for fewer days) any time during the first 90 days of the calendar year
• In a LTC setting you may get a 31 day transition supply any time during the first 90 days of the calendar year.

This policy is in place even if you enroll with a start date of either November 1 or December 1 and need a transition supply.

Emergency supply for current members

If you are in an LTC setting, you may be allowed a 31-day emergency supply as part of the transition process, unless the prescription is written for fewer days, of a drug that is not on the drug list, or your ability to get the drug is limited. In the event that a coverage determination request is still being processed after the 90-day period, you may be able to get an emergency supply. Your LTC pharmacy can call to see if your fill qualifies as an emergency supply.

Treatment of re-enrolled members

You may leave one plan, enroll in another plan, and then re-enroll in the original plan. If this happens, you will be treated as a new member so you are eligible for transition benefits. The transition benefits begin when you re-enroll in your original plan.

Level of care changes

You may have changes that take you from one level of care setting to another. During this level of care change, drugs may be prescribed that are not covered by your plan. If this happens, you and your doctor must use your plan's coverage determination request process.

To prevent a gap in care when you are discharged, you may get a full outpatient supply that will allow therapy to continue once the limited discharge supply is gone. This outpatient supply is available before discharge from a Medicare Part A stay.

When you are admitted to or discharged from an LTC setting, you may not have access to the drugs you were previously given. However, you may get a refill upon admission or discharge.

Transition notices

When you or your pharmacy submit a prescription drug claim for a transition supply, a letter is sent to you by first class U.S. mail within three business days of the date your drug claim is submitted. Efforts are made to notify doctors when a prescription they write for a member results in a transition supply. This letter is sent to explain the following information:

• That the transition supply is temporary and may not be refilled unless a coverage determination request is approved
• That you should work with your doctor to find a new drug option that is on your plan's drug list
• That you can request a coverage determination and how to make the request, timeframes for processing requests, and the appeal rights if the coverage determination is not approved

Cost considerations

You will be charged the cost share amount for a transition supply of drugs provided, as follows:

• For low income subsidy (LIS) members, you will not be charged a higher cost sharing for transition supplies than the statutory maximum copayment amounts.
• For non-LIS enrollees, you will be charged:
  • The same cost share amount for Part D drugs that are not on the drug list that you would be charged for drugs approved through a formulary exception; or
  • The same cost share amount for drugs on the drug list with UM edits that would apply if the UM criteria were met.

When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. (Please, also see the description of the exceptions process.) You must contact us if you would like to request a Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx coverage determination, including an exception. You cannot request an appeal if we have not issued a coverage determination.

The following are examples of when you may ask Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx for a coverage determination:

• If you are not getting a prescription drug that you believe Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx covers.
• If you received a Part D prescription drug that you believe Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx covered while you were a member, but the plan refused to pay for the drug.
• If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped and that you believe you have extenuating circumstances that should exclude you from the reduction/non-coverage.
• If there is a limit on the quantity (or dose) of the drug, and you disagree with the requirement or dosage limitation.
• If you bought a drug at a pharmacy that is not in the network and you want to request reimbursement for the expense.

How do I make a request for a coverage determination?

To ask for a standard decision, you or your appointed representative may call the Customer Service number for your plan, deliver a written request, or send a fax or email. 

By phone

7 days a week, 8 a.m. to 8 p.m. 

Blue Medicare HMO

888-310-4110, TTY 711 

Blue Medicare PPO

877-494-7647, TTY 711

Blue Medicare Rx

888-247-4142, TTY 711

Deliver a written request

You can deliver a written request to Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx at:

5660 University Parkway

Winston-Salem, NC 27105

Monday through Friday from 8 a.m. to 5 p.m.

By fax

You may fax your request to 888-446-8535.

By email

An email request for coverage determination or Part D exception must include the member's:

• Full name
• Member ID number (see your member ID card)
• Date of birth
• Phone number
• The name of the drug for which the coverage determination or Part D exception is being requested
• The name and telephone number of the person who prescribed the drug

To request for a Prescription Drug Coverage Determination requiring authorization such as Non Formulary, Prior Authorization, Quantity Limits, Tier Exceptions, or Step Therapy, please send your email to: PartDExceptions@bcbsnc.com

Forms may be submitted to this email address or mailed to the address located on the form.

• Coverage Determination Form (PDF)

To request reimbursement of a Prescription Drug for purchases you have already made, please send your email to: PartDClaims@bcbsnc.com 

Forms may be submitted to this email address or mailed to the address located on the form.

• Blue Medicare Prescription Drug Claim Form (PDF)

Requesting an expedited decision

To ask for a fast decision, you, your physician, or your appointed representative may contact us using the above information. After regular business hours, you should consult with a network pharmacy regarding your need for an emergency or temporary supply of medication until you can contact the Plan the next business day. Be sure to ask for a "fast," "expedited," or "24-hour" review. NOTE: You cannot ask for a fast decision on a request for coverage of a drug already purchased.

When will I hear back with a decision?

Generally, we must make our decision no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. If your request involves a request for an exception (including a formulary exception or an exception from utilization management rules, such as dosage or quantity limits), we must make our decision no later than 72 hours after we have received your doctor's "supporting statement," which explains why the drug you are asking for is medically necessary.

If you are requesting an exception, you should submit your prescribing doctor's supporting statement with the request, if possible. We will give you a decision in writing about the prescription drug you have requested. You will get this notification when we make our decision under the timeframe explained above. If we do not approve your request, we must explain why and tell you of your right to appeal our decision.

If you get a fast review, we will give you our decision within 24 hours after you or your doctor ask for a fast review-sooner if your health requires. If your request involves a request for an exception, we must make our decision no later than 24 hours after we get your doctor's "supporting statement." Requests for reimbursement of prescriptions you have already purchased are responded to with 14 days after we have received the request.

Exceptions are part of the coverage determination process. You, your authorized representative, or your prescribing physician may request an exception to seek coverage of a drug that:

• Is not on the formulary
• Requires prior authorization
• Has quantity limitations

Example of an exception request:

If the Plan's formulary does not include a drug that you or your prescribing physician feel is necessary, then you or your prescribing physician may request an exception so that you may obtain coverage of this drug. If the Plan does not grant the requested exception, then you or your prescribing physician may file an appeal.

How do I make an exception request?

You or your prescribing physician may request an exception to the coverage rules for your Medicare prescription drug plan via:

Blue Medicare HMO:

888-310-4110 (For the hearing and speech impaired: TTY 711)

Blue Medicare PPO:

877-494-7647 (For the hearing and speech impaired: TTY 711)

Blue Medicare Rx (PDP):

888-247-4142 (For the hearing and speech impaired: TTY 711)

Seven days a week, 8 a.m. - 8 p.m.

Physicians should call:

336-774-5400 or toll free:

Blue Medicare HMO at 888-310-4110

Blue Medicare PPO at 888-296-9790

Blue Medicare Rx at 888-298-7552

Mail:

Blue Medicare HMO or Blue Medicare PPO

c/o Blue Cross NC

Attn: Rx Coverage Determination

P.O. Box 17509

Winston-Salem, NC 27116-7509

Blue Medicare Rx

c/o Blue Cross NC

Attn: Rx Coverage Determination

P.O. Box 17509

Winston-Salem, NC 27116-7509

A specific form is not required for you to make an exception request, although there are Blue Cross NC forms available to you and your physician to request an exception or prior approval for a drug. The request must include your prescribing physician's statement that he/she has determined that the preferred drug either would not be as effective for you and/or would have adverse effects for you.

When will I receive a decision on my exception request?

We will review the exception request and notify both you and your prescribing physician of our decision as soon as your health requires, but no later than 72 hours from the time we receive your physician's supporting statement. Faster exception decisions are available if this 72-hour time frame could seriously harm your health or ability to function.

If the decision is not in your favor, the notice will be given by phone followed by a written notice within three business days. The notice will tell you how to pursue your appeal rights if you are dissatisfied with our decision.

How is out-of-network defined?

Generally the term out-of-network refers to the use of providers that are not contracted to provide services to Blue Medicare HMO or Blue Medicare PPO members. In some situations, the use of out-of-network providers is permissible. There are several specific situations in which coverage may be available out-of-network:

• You are in an emergency situation and need access to a covered Part D drug.
• You are traveling outside of the service area; run out of or lose the covered drug(s)or become ill and need a covered drug and cannot access a network pharmacy.
• You cannot obtain a covered drug in a timely manner within your service area, because for example, there is no network pharmacy within a reasonable driving distance that provides 24-hour-a-day/7-day-per-week service.
• You reside in a long-term care facility and the contracted long-term care pharmacy does not participate in the plan's pharmacy network.
• You must fill a prescription for a covered drug, and that particular drug is not regularly stocked at accessible network retail or mail-order pharmacies (for example, an orphan drug or other specialty pharmaceutical typically shipped directly from manufacturers or special vendors).
• You are evacuated or displaced from your residence due to a state or federally declared disaster or health emergency.

What is excluded from out-of-network coverage?

Routine use of an OON pharmacy is not permitted by a member who resides in a location where adequate pharmacy access exists (please refer to the pharmacy access standards). Members are encouraged to use network pharmacies unless one of the specific OON situations listed above applies.

In the situations listed above, will I have prescription drug coverage?

Yes, we will pay up to our allowed amount for the drug minus any applicable copay or coinsurance.

What do I need to do if I need to get a prescription drug at an out-of-network retail pharmacy?

For one of the out-of-network situations described above, you will need to do the following:

• Pay full charges at the non-network pharmacy.
• File the claim via paper claim form for reimbursement.

What will I be reimbursed?

There are two reimbursement scenarios for the out-of-network benefit. These are:

• If you live in a county that does not have adequate access to a participating pharmacy - in this situation, after you submit your paper claim, you will be reimbursed up to the plan's allowed amount minus your cost share.
• If you live in a county with adequate access to a participating pharmacy - if you use an out-of-network (or non-participating) pharmacy in counties with adequate access, you will be reimbursed up to the plan's allowed amount minus your cost share. You must meet one of the five allowable circumstances outlined above. Routine use of an out-of-network pharmacy will require that you pay 100% of the charges.

Please note that in emergency situations, you will be reimbursed the entire amount minus your member cost share amount.

What are the pharmacy access standards?

Medicare categorizes the pharmacy access standards into three categories: urban, suburban and rural. These access standards vary based upon locale as listed below.

• Urban - On average, 90% of members who live in an urban area have access to a retail network pharmacy within 2 miles of their residence;
• Suburban - On average, 90% members who live in an suburban area have access to a retail network pharmacy within 5 miles of their residence; and
• Rural - At least 70% of members, on average, have access to a retail network pharmacy within 15 miles of their residence.

How do I know if there is a pharmacy that meets the access standards for where I live?

You can either call the Customer Service number on the back of your ID card and ask the representative, or search our online pharmacy directory.

What drugs and vaccines are generally dispensed and administered in the physician office setting?

Certain drugs and vaccines not covered under Medicare Part B may be covered by Blue Medicare HMO or PPO. In many cases these drugs and vaccines will require prior approval to be requested and approved before coverage can be provided under Blue Medicare HMO or PPO benefit.

Medicare Part D benefits exclude the following types of drugs or drug classes from coverage:

• Agents when used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose such as morbid obesity)
• Agents when used to promote fertility
• Agents when used for cosmetic purposes or hair growth
• Agents when used for the symptomatic relief of cough and colds
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
• Nonprescription drugs
• Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee
• Agents when used for the treatment of sexual or erectile dysfunction

Refer to the Excluded Drugs list (PDF). Please keep in mind the attached list is updated quarterly and is not all inclusive. You can also refer to your Evidence of Coverage for more information.

Members enrolled in Blue Medicare HMO℠ or Blue Medicare PPO℠ with Medicare prescription drug benefits or Blue Medicare Rx℠ may be eligible for the Medication Therapy Management Program (MTMP), in accordance with CMS requirements. The Medication Therapy Management Program helps members understand their medications better.

Who's eligible for the MTMP?

1. Individual members eligible for the MTMP services must meet all three (3) criteria below:

• Have at least three (3) of the following chronic conditions: diabetes, chronic obstructive pulmonary disease (COPD), high blood cholesterol, chronic heart failure (CHF), or rheumatoid arthritis
• Take at least eight (8) or more prescription medications covered by Part D
• Expect to spend more than $4,935 in 2023 on prescription medicines covered by Medicare Part D

and/or

2. Have an active coverage limitation for an opioid or frequently abused medicine as a result of a Drug Management Program.

What services does the MTMP provide?

The MTMP services include the following interventions for members and prescribers.

• An annual comprehensive medication review (CMR) with a pharmacist to go over prescription and non-prescription medications that you take.
• Quarterly Targeted Medication Reviews which look for any safety or other issues which may need attention. The member’s prescriber may be contacted if any issues are found.

What is a CMR?

A Comprehensive Medication Review (CMR) is a person-to-person review of your medications with a pharmacist or nurse. The appointment usually takes about thirty (30) minutes. During that time the pharmacist will:

• Review the medicines you take
• Create a personal medicine list
• Help you understand how your medicines work
• Tell you about side effects from your medicines
• Answer any questions or concerns you have

How do eligible members enroll?

• If you are eligible, you will be automatically enrolled in the program. Eligible members will receive a letter inviting them to schedule a medication review with a pharmacist.
• You may return the participation form in the mail OR call a toll-free phone number (866-686-2223 or TTY users call 711) between 10:00 a.m. and 6:00 p.m. Eastern Time, Monday through Friday (except major holidays).
• Participation in the program is voluntary.

How do members opt out (decline) participation in the program?

Members may opt out from participating in the program.

This can be done by calling the telephone number listed in the notification letter (866-484-3953 or TTY users call 711, 24 hours a day, 7 days a week).

When prompted, enter your opt-out personal security PIN.  You may refuse individual services without having to opt out from the whole program.

What are the program goals?

• Educate members regarding their medications
• Increase understanding about how to take medications as prescribed
• Identify and prevent medical complications related to medication therapy

Safe disposal of your medicines

We want to be sure you know you have options to safely dispose of the unused medicines you take. You can get rid of your expired, unwanted, or unused medicines through a drug take back site or sometimes at home. Unused medicines should be disposed of as soon as possible.

Do you know how to safely dispose of your medicines?

Local take back sites are the preferred way to dispose of unused medicines.

Search for more local take back sites at:

https://apps2.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s1

When a take back option is not close by, there are two ways to dispose of medicines at home, depending on the drug.

Flushing medicines: If you don’t have a drug take back site near you, check the FDA’s flush list at https://www.fda.gov/consumers/consumer-updates/where-and-how-dispose-unused-medicines to see if your medicine is on the list. Medicines on the flush list are those (1) wanted for their misuse and/or possible abuse and (2) that can result in death from one dose if not taken the right way.

Dispose of medicines in household trash: If your medicine is not on the flush list, you should follow these steps to get rid of the medicine in your trash at home:

1. Mix medicines (liquid or pills; do not crush tablets or capsules) with a substance such as dirt, cat litter or used coffee grounds.
2. Place the mixture in a container such as a sealed plastic bag.
3. Throw away the container in your trash at home.
4. Remove or scratch out all personal details on the label of empty medicine bottles or packaging, then throw away in your home trash or recycle the empty bottle or packaging.

For more information go to www.deatakeback.com.

If you have a question about how to dispose of your medicine, ask your doctor, pharmacist, or contact Customer Service at the phone number on the back of your member ID card.

If you have additional questions:

For more information regarding the MTMP and a Personal Medication list from a CMR, please click on the following:

• MTMP (from the sign in screen, select your Plan type to continue)
• Personal Medication List (PDF)

Members should also refer to their Evidence of Coverage for more details on the MTMP.  These programs are not considered a benefit.