Non-Formulary Exception Criteria Medicare Part D

Non-formulary Exception Criteria for Approval

1. The member must have tried at least two alternative formulary drugs that have a similar mechanism of action as the requested drug AND the member either did not respond to or did not tolerate the formulary alternative drugs. If two drugs with a similar mechanism of action are not available on formulary, the member must have tried two alternative formulary drugs that are medically acceptable to treat the member’s condition. (NOTE: if the requested drug is a multisource brand and the generic equivalent is covered on the formulary, the member must have tried and failed the generic drug equivalent, as one of the two required formulary alternatives.); OR 
2. The prescriber provides an explanation of why formulary alternative drugs would not be as effective in treating the member’s condition and/or would cause the member to have adverse effects. 

Length of approval: 12 months

Multi-language Interpreter Services

ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call the Customer Service or TTY number on the back of your member ID card. 

ATENCIÓN: Si habla otro idioma, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a Servicio de Atención al Cliente al número de teléfono para personas con problemas auditivos (TTY) que figura al dorso de su tarjeta de identificación.

注意：他の言語を話す方は、言語支援サービスを無料でご利用いただけます。 顧客サービスにお電話いただくか、会員IDカードの裏面にあるTTYサービスをご利用ください。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số Dịch vụ khách hàng hoặc TTY trên mặt sau thẻ ID thành viên của bạn.

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 가입자 ID 카드 뒷면에 있는 고객 서비스 혹은 TTY 번호로 전화해 주십시오.

ATTENTIONₒ: si vous parlez une autre langue, des services d'aide linguistique vous sont proposés gratuitement. Contactez le service clients au numéro figurant au dos de votre carte de membre.

النيص املوضح عىل ظهر بطاقة هوية العضو. ملحوظة: إذا كنت تتحدث اللغة العربية، فإن خدمات املساعدة اللغوية تتوافر لك باملجان. اتصل برقم خدمة العمالء أو رقم الهاتف

LUS CEEB TOOM:Yog tias koj hais lus Hmoob, , peb muaj kev pab txhais lus pub dawb rau koj. Hu rau Customer Service tus xov tooj los yog tus xov tooj TTY rau cov neeg tsis hnov lus zoo uas nyob sab tom qab koj daim npav ID.

ВНИМАНИЕ: Если вы говорите на другом языке, то вам доступны бесплатные услуги перевода. Позвоните в Отдел обслуживания по номеру, указанному на обратной стороне вашей идентификационной карточки участника.

PAUNAWA: Kung nagsasalita ka ng ibang lengguwahe, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tawagan ang numero ng Customer Service o TTY sa likod ng iyong member ID card.

� ૂચના: જો તમે�ુજરાતી બોલતા હોવ તો તમારા માટ ભાષા સેવાઓ િ ન:�ુ�ક �પલ�� છે. તમારા સ��પ� ઓળ�પ�રની (આઈ.ડ�) પાછળની બા�ુપર આપેલ �રાહક સેવાઓના ન ંબર અથવા TTT ન ંબર પર કૉલ કરો.

ចំណំ៖ ប្រសិនប្របោកអ្នកនិយាយជាភាសាខ្មែរ ្រសវាកមជំនួយម្កភាសាមាន្្តល់ជូនស្រមាបបោកអ្នកបោយមិនគិតថ្លៃ។សូមបៅបៅកា វាអតិ្ជនបោយ្រប្រ្រលទូរស័ព្ទបៅខាង្្នងកាតសមាជិកបរស់បោកអ្នក។ ន់្រស

ACHTUNG: Falls Sie eine andere Sprache sprechen, stehen Ihnen kostenlose Sprachdienste zur Verfügung Rufen Sie die Nummer des Kundenservices oder von TTY an, die auf der Rückseite Ihrer Mitgliedskarte angegeben ist. .

न द: यिद आप दसरी भाषा बोलतेह, तो आपकेलए भाषा सहायता सेवाएं, मु म, उपल ह। अपने

सदआईडी काडर्केपीछे मौजूद ग्राहक सेवा या TTY नंबर पर कॉल कर

ເຊີນຊາບ: ຖ້າທ່ານເວົ້າພາສາອື່ນ, ມີການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາໃຫ້ທ່ານໂດຍບໍໄດ້ເສຍຄ່າ. ໂທຫາຝ່າຍບໍລິການລູກຄ້າຫລື ເບີ TTY ຢູ່ດ້ານຫຼັງບັດປະຈຳຕົວຂອງທ່ານ.

注意：如果您講廣東話或普通話， 您可以免費獲得語言援助服務。請撥打您會員 ID 卡背面的客服或 TTY號的電話號碼。

Non-Discrimination and Accessibility Notice

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) provides:

• Free aids and services to people with disabilities to communicate effectively with us, such as: qualified interpreters and/or written information in other formats (large print, accessible electronic formats, etc.)
• Free language services to people whose primary language is not English, such as: qualified interpreters and/or information written in other languages 

If you need these services, call the Customer Service or TTY number on the back of your member ID card. If you believe that Blue Cross NC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with:
Blue Cross NC, P.O. Box 2291, Durham, NC 27702 Attention: Civil Rights Coordinator-Privacy, Ethics & Corporate Policy Office Call: 919-765-1663, 1-888-291-1783 (TTY) Fax: 919-287-5613 E-mail: civilrightscoordinator@bcbsnc.com

You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, the Civil Rights Coordinator-Privacy, Ethics & Corporate Policy Office is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at:
Online: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf
Mail: U.S. Department of Health & Human Services 200 Independence Avenue, SW Room 509F HHH Building Washington, D.C., 20201
Call: 1-800-368-1019, 1-800-537-7697 (TDD)
Complaint forms are available online 

This notice and/or attachments may have important information about your application or coverage through Blue Cross NC. Look for key dates. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. If you need these services, call the Customer Service or TTY number on the back of your member ID card. 

Discrimination is Against the Law

• Blue Cross NC complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. 
• Blue Cross NC does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.