This plan uses a prescription drug formulary.1 Benefits are limited to the drugs on this formulary unless an exception is approved by the plan.
Drugs that are excluded include:
- 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.
- 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.
- Certain drugs have quantity limits.
- Certain drugs require prior authorization.
- Certain drugs require step therapy.
- Drugs covered by Medicare Part B are not payable as Part D benefits. (Refer to your Medicare Part B coverage documents for Part B drug coverage.)
- Compounded medications require an exception request to be approved
- Members must use network pharmacies to receive full benefits.
- Drug benefits or services not described in the plan formulary or the Evidence of Coverage, or not required by law or regulations, are not covered.
- Prescriptions filled by pharmacies outside the United States, even for a medical emergency are not covered.
- Replacement of lost or stolen prescriptions are not covered.
- Prescriptions filled prior to effective date of coverage or after disenrollment date are not covered.
- Enhanced coverage gap drug benefits - In the coverage gap, you pay only a copayment for Tier 6 preferred generics and 25% coinsurance for all other generics. Your coinsurance for approved brand-name drugs is 25%.
- Standard coverage gap drug benefits - In the coverage gap, you pay 25% coinsurance for all generics. Your coinsurance for approved brand-name drugs is 25%.
- Medications cannot be refilled before 75% of the time period for the supply has passed. For example, if the prescription is written for a 30-day supply, then you may obtain a refill beginning on the 23rd day.
- An exception request for a Tier 5 (Specialty Tier) drug to be paid at the brand or generic cost sharing level is not permissible under this plan.
- A Medicare beneficiary must be entitled to Part A and enrolled in Part B to enroll in a Medicare Advantage plan.
- In order to enroll in a Blue Medicare HMO or Blue Medicare PPO plan, you must reside within the CMS approved service area.
- After the initial enrollment period, there are limits on when and how often you may enroll in or change Medicare Advantage plans.
- If a Medicare beneficiary is eligible for Part D, and does not sign up in the initial enrollment period, a Medicare late enrollment penalty may apply.
- The plan's contract may be canceled by either the plan or the Centers for Medicare & Medicaid Services.
- Members enrolled under this plan may not have drug coverage through both a Medicare Part D prescription drug plan and a Medicare supplemental plan.
- Plan benefits and premium are subject to change annually.
- All claims must be received within 3 years of the fill date. For example, if a drug is purchased on January 31, 2019, the claim must be received no later than January 31, 2022. Claims received after this time frame will not be eligible for coverage.
Blue Cross and Blue Shield of North Carolina is an HMO, HMO-POS PPO and PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal.
Blue Cross and Blue Shield of North Carolina Senior Health DBA Blue Cross and Blue Shield of North Carolina is an HMO-POS D-SNP plan with a Medicare contract and a NC State Medicaid Agency Contract (SMAC). Enrollment in Blue Cross and Blue Shield of North Carolina Senior Health depends upon contract renewal.
Blue Medicare Supplement plans offered: [Plan A: BMS A, 2/22, Plan G: BMS G, 2/22, Plan HI DED G: BMS HDG, 2/22, Plan K: BMS K, 2/22, Plan N: BMS N, 2/22.]
Blue Cross and Blue Shield of North Carolina does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, sexual orientation or source of payment. All Blue Cross and Blue Shield of North Carolina items and services are available to all eligible beneficiaries in the service area.
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Formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.
The information on this page is current as of 10092022 | Y0079_11785_M CMS Accepted 10092022 | U36079, 092020
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
© 2023 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross NC is an abbreviation for Blue Cross and Blue Shield of North Carolina. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.