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Important Legal Information and Disclaimers

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

Doctors, Rx and Pharmacy

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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.)
  • Compounded medications require an exception request 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.
  • 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 51% coinsurance for all other generics. Your coinsurance for approved brand-name drugs is 40%.
  • Standard coverage gap drug benefits - In the coverage gap, you pay 51% coinsurance for all generics. Your coinsurance for approved brand-name drugs is 40%.
  • 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 (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, 2015, the claim must be received no later than January 31, 2018. 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 10/1/2016.

Y0079_7520 CMS 10042016