Blue Medicare HMO and Blue Medicare PPO Limitations and Exclusions
- 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:
- 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
- Drugs used to treat sexual or erectile dysfunction
- Drugs that are not Food & Drug Administration approved.
- Outpatient drugs for which the manufacturer requires that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of selling the drug.
- Certain drugs will have maximum quantity limits.
- Certain drugs require prior authorization.
- Certain drugs may 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.)
- 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 coverage gap drug benefits - In the coverage gap, you pay only a copayment for Tier 1 preferred generics and 58% coinsurance for all other generics. Your coinsurance for approved brand-name drugs is 45%.
- Standard coverage gap drug benefits - In the coverage gap, you pay 58% coinsurance for all generics. Your coinsurance for approved brand-name drugs is 45%.
- 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 5 (Specialty Tier) drug to be paid at the brand or generic cost sharing level is not permissible under this plan. Tier exceptions are only permissible for Tier 4 (Non-Preferred Brand) and Tier 2 (Non-Preferred Generic) drugs.
- 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, 2014, the claim must be received no later than January 31, 2017. Claims received after this time frame will not be eligible for coverage.
1 Formulary and pharmacy network may change at any time. You will receive notice when necessary.
Important Legal Information and Disclaimers
The information on this page is current as of 10/1/2015.
Y0079_7169 CMS Approved 11102015