Blue Medicare Rx Exclusions and Limitations

• This plan uses a prescription drug formulary. Benefits are limited to the drugs on this formulary unless an exception is approved by the plan.
• Drugs that are excluded include:
  • Drugs used for anorexia, weight loss, or weight gain
  • Drugs used to promote fertility
  • Drugs used for cosmetic purposes or hair growth
  • Drugs used for the symptomatic relief of cough and colds
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
  • Non-prescription drugs
  • Inpatient drugs
  • Barbiturates (sleeping pills)
  • Benzodiazepines (central nervous system depressants)
  • Drugs used to treat sexual or erectile dysfunction
• Certain drugs will have maximum quantity limits.
• Certain drugs require prior authorization.
• 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.)
• 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.
• Cosmetic products, or any drug used for cosmetic purposes (such as Rogaine, Renova, Propecia, Avage, Botox Cosmetic,Vaniqa) are not covered.
• Over-the-counter (OTC) medications and any prescription medication that contains the same active ingredient(s) as an existing over-the-counter medication 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 Plan Only – In the coverage gap, coverage is limited to generic drugs. (With Standard Plan, there is no drug coverage in the coverage gap.)
• Coverage is not available for refill medications 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 drugs on the Brand Name or Specialty Tiers to be paid at the generic cost sharing level is not permissible under this plan.
• An exception request for a Tier 4 (Specialty Tier) drug to be paid at the brand or generic cost sharing level is not permissible under this plan.
• Drugs with Quantity Limitations may not be refilled until 100% of the time period for the supply has passed. For example, if the prescription is written for a supply of 10 tablets to be used in a 30-day period, then you may obtain a refill beginning on the 31st day.
• 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 the Blue Medicare Rx, you must reside within North Carolina. If you are in prison, you cannot join this plan.
• After the initial enrollment period, you may not be able to switch plans until the next open enrollment period.
• If you are eligible for Part D, and don't sign up in your initial enrollment period, you may have to pay more if you sign up later, due to a Medicare late enrollment penalty.
• 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 12 months of the fill date or 3 months after benefit period end date, whichever is earliest. For example, if a drug is purchased on January 31, 2010, the claim must be received no later than January 31, 2011. However, if a drug is purchased on May 31, 2010, the claim must be received no later than March 31, 2011. Claims received after this time frame will not be eligible for coverage.

BCBSNC is a prescription drug plan sponsor with a Medicare contract. Prescription drug coverage is not sold as a benefit of any Medicare supplement plan.

The information on this page regarding Blue Medicare Rx Plans is current as of 08/17/07.

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The information on this page is current as of 10/01/2009.