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Important Legal Information and Disclaimers

Blue Medicare HMO, Blue Medicare PPO, and Blue Medicare Rx (PDP) Members

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Blue Medicare Rx Frequently Asked Questions

The information outlined in these FAQs, especially the information regarding enrollment periods, is intended for people age 65 and people eligible for Medicare.

Q: Whom do I call if I have questions? top

A: If you have questions regarding your Blue Medicare Rx, please call BCBSNC Customer Service toll-free at 1-888-247-4142, 7 days a week, from 8 a.m. to 8 p.m. TTY users should call 1-888-247-4142 (toll-free), 7 days a week, from 8 a.m. to 8 p.m. If you have questions in general about Medicare prescription drug coverage or about Medicare, you may call Medicare at 1-800-633-4227. TTY/TDD users may call Medicare at 1-877-486-2048.

Q: What is Medicare prescription drug coverage? top

A: As of January 1, 2006, Medicare began offering prescription drug coverage to help you pay for the prescription drugs you need. The coverage is designed to help you by covering prescription drugs at participating pharmacies close to where you live and through mail order.

Everyone with Medicare is eligible for this new coverage; however, the coverage is not mandatory. It is a voluntary program that you may choose to purchase annually.

Medicare prescription drug coverage is insurance. Private companies, like Blue Cross and Blue Shield of North Carolina provide the coverage.

Q: How does the coverage work? top

A: Medicare has designed a "standard benefit." Companies may offer additional enhanced plans, but they must offer a standard benefit package that is at least equal in value to Medicare's standard benefit as follows:

5% coinsurance - After your total out-of-pocket costs reach $4,950, you will pay very little for prescription drugs. You will pay only 5% (or $3.30 generic/$8.25 brand name, whichever is greater) for prescription drugs and your insurance company will pay the rest.
100% coinsurance - After your total drug costs reach $3,700, you will be responsible for all of your prescription drug costs until you reach an annual out-of-pocket limit of $4,950. This is referred to as the "coverage gap."
25% coinsurance - After the first $400, you will be responsible for 25% of the total cost of your prescription drugs. The Plan will pay 75% of your total drug costs until they reached a total of $3,700.
$400 deductible - You will be responsible for 100% of the first $400 in total prescription drug costs in each calendar year before your prescription drug benefit begins.

Q: How will I know if my medications are on the BCBSNC formulary1? top


  1. You can search for specific drugs online.
  2. You can call BCBSNC Customer Service toll-free at 1-888-247-4145, 7 days a week, from 8 a.m. to 8 p.m. TTY users should call 1-888-247-4142 (toll-free), 7 days a week, from 8 a.m. to 8 p.m.

Q: What drugs are covered under Medicare prescription drug coverage? top

A: Each plan provider will establish its own formulary, or list of prescription drugs, that it will cover. Although formularies must meet certain requirements set by Medicare, they still differ by plan.1

Medicare prescription drug coverage will include:

  • Prescription drugs
  • Vaccines
  • Insulin
  • Certain medical supplies associated with the injection of insulin (syringes, needles, alcohol swabs and gauze).

Generally speaking, Medicare prescription drug coverage covers drugs that meet the following criteria:

  • They must be available only by prescription
  • They must be approved by the Food and Drug Administration
  • They must be used and sold in the United States
  • They must be used for a medically necessary prescription

Certain drugs, or classes of drugs, will not be covered because they are excluded by law, such as over the counter medicines like aspirin.

To learn which drugs are covered by BCBSNC Blue Medicare Rx (PDP) plans, search our list of covered drugs, formulary (list of covered drugs).1

Q: Which pharmacies participate? top

A: Click here to Find a Pharmacy.1

Q: Are mail-order drugs available through Medicare prescription drug coverage? top

A: You have the convenience of ordering your prescriptions from the mail order pharmacy. You can purchase up to a 90-day supply through mail order, and your medications will be delivered directly to your home. Depending on your plan, there may be savings available to you if you use the mail option.

Q: Can I change plans when I want to? top

A: Congress designed Medicare prescription drug coverage on an annual enrollment cycle. This means that each year, you will have the option to re-enroll in your existing Medicare prescription drug coverage plan or change plans between October 15 and December 7 each year.

You may also have another opportunity during the year to switch plans, under limited circumstances. For example, if you move out of your plan's service area, you'll have an opportunity to choose another plan that serves your new area.

Q: Must I continue to pay my Medicare Part B premium? top

A: Yes. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

Q: Whom do I call if I have questions regarding late enrollment penalty? top

A: For questions regarding late enrollment, you may call BCBSNC at 1-888-247-4142. TTY users should call toll-free 1-888-247-4145.

Q: What if I have a limited income? top

A: If you have Medicare and have limited income and resources, you may qualify for special financial assistance to help you pay for your Blue Medicare Rx costs. The amount of assistance you qualify for will depend on your income and resources:

In 2016, if your annual income is below $17,820 for a single person (or $24,030 if you are married and living with your spouse), you may qualify for financial assistance. Slightly higher income levels may apply if you provide half support to other family members living with you. If your resources (including your savings and stocks, but not counting your home or car) are under $13,640 (for a single person) or under $27,250 (for a married couple) you may qualify for financial assistance.2 Beneficiaries interested in qualifying for extra help with Blue Medicare Rx costs should call:

Medicare at 1-800-MEDICARE (1-800-633-4227)

TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week. Your state Medicaid office The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778. If you qualify for extra help with your Blue Medicare Rx, your premium and drug costs will be lower. When you join BCBSNC, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay.

1 Formulary and Pharmacy networks may change at any time. You will receive notice when necessary.

2 October, 2015.

Important Legal Information and Disclaimers

®, SM Mark of the Blue Cross and Blue Shield Association. SM1 Mark of Blue Cross and Blue Shield of North Carolina.

The information on this page is current as of 10/1/2016.

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