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Important Legal Information and Disclaimers

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

Policies and Procedures

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Prior authorization, tier exceptions, nonformulary exceptions, step therapy, and quantity limitations

Prior authorization, step therapy, and exception requests require members to meet certain clinical criteria prior to a drug being covered. For prior authorization, step therapy, and exception requests, the member or the member's prescribing physician may contact Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx. A physician's supporting statement is required for all requests before the prescription can be approved for payment. Physicians may contact the plan by calling Blue Medicare HMO at 1-888-310-4110, Blue Medicare PPO at 1-888-296-9790 or Blue Medicare Rx at 1-888-298-7552 or using the applicable fax request form (see below) to request an exception. After normal business hours messages can be left on the Part D After Hours Exception voice mail. Please see the member's formulary for detailed information regarding covered drugs and drugs requiring prior approval.

Exception requests

Requests for non-formulary drugs (those not covered by the member's plan) and requests that a nonpreferred drug be covered at a lower co-payment can be made with the non-formulary or the tier exception request form. These forms should list formulary drug alternatives that may have been tried by the member for the same condition, what the outcomes of those drugs were, or the clinical reason these drugs would not be expected to be as effective or safe as the drug being requested. Please provide all information requested on the forms to ensure a prompt review. Incomplete forms can result in a denial of the exception request.

Non-formulary drug requests must meet Part D drug coverage criteria, i.e., the drug must be medically necessary and must be prescribed for an approved indication.

Tier exception requests

Blue Medicare HMO/PPO Tier exception request form

Blue Medicare Rx Tier exception request form

Hospice requests

The following forms should be used to request coverage of prescription medications under Medicare Part D when the member is in Hospice care when it is believed the drug should not be covered under the Part A hospice benefit.

Blue Medicare HMO/PPO Hospice fax form

Blue Medicare Rx Hospice fax form

Drugs that require prior authorization

Certain drugs require prior authorization before coverage. Prior authorization is a program that requires members to meet certain criteria prior to a drug being covered. Prior authorization may be used to encourage the appropriate use and dose of prescribed medication based on the U.S. Food and Drug Administration (FDA) approved labeling and other medical literature. Prior authorization may also be used to determine if a drug's use meets criteria for coverage under Medicare Part B or Part D. Please see the member's formulary for drugs that require prior authorization. These drugs will have "prior authorization required" listed next to the drug. Information may need to be submitted describing the use and setting of the drug to make the determination.

2015 Prior Authorization

Blue Medicare HMO Standard, Blue Medicare HMO Enhanced and Blue Medicare PPO

Blue Medicare HMO Essential

Blue Medicare Rx Enhanced

Blue Medicare Rx Standard

Some Drugs may be covered by Medicare Part B or Medicare Part D

Drugs that are currently authorized by law as covered under Medicare Part B will remain covered under Medicare Part B and should be billed to the Part B payer. (See the CMS Coverage database at or DME-MAC Jurisdiction C at for Part B drug coverage clarification.)

Below is a list of medications/drug classes that may be covered under Medicare Part B or Part D (Blue Medicare HMO, Blue Medicare PPO, and Blue Medicare Rx) depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

Drug/Drug Class Covered Under Part B for the following indications
(Summary provided: See DMERC policies and CMS guidance for specific criteria):
Short and rapid-acting Insulins When used in a pump
End Stage Renal Disease
ESRD-related prescription drugs included in the bundled prospective dialysis facility payment.
Nebulized gentamicin
Cystic fibrosis
Nebulized tobramycin (TOBI) Cystic fibrosis
Nebulized pentamidine (Nebupent) HIV
Complications of organ transplant
Inhalation drugs Certain inhalation drugs are generally covered when used with a nebulizer in the home. (SNF and others cannot be considered "home" (see CMS guidance)
Immunosuppressive drugs For a beneficiary who has received a Medicare-covered organ transplant
Oral anti-emetics drugs Oral anti-nausea drugs used as part of an anticancer chemotherapeutic regimen as a full therapeutic replacement for an IV anti-emetic drug within 48 hours of chemo administration.
Hepatitis B vaccine The vaccine is administered to a beneficiary who is at high or intermediate risk of contracting hepatitis B.
Erythropoietin For the treatment of anemia for persons with chronic renal failure who are on dialysis.
Intravenous immune globulin (IVIG) Provided in the home for a diagnosis of primary immune deficiency disease
Parenteral nutrition For patients who cannot absorb nutrition through their intestinal tract (nonfunctioning digestive tract)
Infusable drugs Infused using an implantable pump or infused using an external pump in the home (SNF and others cannot be considered "home")
Osteoporosis Provided by a home health agency to females meeting coverage criteria for home health benefit and criteria found in the MA Benefit Policy Manual, Section 50.4.3

If these medications are not eligible for coverage under Part B, they may be covered under Part D with prior approval by the plan. Examples of drugs always covered under Part B:

  • Pneumococcal vaccine
  • Influenza vaccine
  • Antigens
  • Blood clotting factors

Step therapy

In some cases, members are required to first try one drug to treat their condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. These drugs will have "step therapy required" listed next to the drug.

Quantity limitations

Certain medications have a designated quantity that will be covered. These limits are designed to identify the excessive use of drugs which may be harmful in large quantities, to highlight the potential need for a different type of treatment, and to match dosing recommendations/requirements set by the manufacturer and the FDA. For some of these medications, if the prescriber feels it is medically necessary to exceed the set limit, he/she must get prior approval before the higher quantity can be covered.




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1 All services are subject to the allowed amount charge. When using out-of-network providers, any amount charged over the allowed amount may be your responsibility.

Important Legal Information and Disclaimers

The information on this page is current as of 09/30/2015.

Y0079_7169 CMS Approved 11102015