60-day notice regarding formulary changes

If you are affected by a change in which your drugs are removed from the formulary (no longer covered), or in which your drugs are moved to a tier requiring a higher member copayment, Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx will mail you a notification. This notification will be sent at least 60 days before the formulary change will take effect. The plan will tell you why the change is being made and will list alternative drugs with expected costs.

You are encouraged to use this 60-day time frame to have your drug switched to an appropriate alternative medication. You also have the option to ask Blue Medicare HMO, Blue Medicare PPO, or Blue Medicare Rx for a coverage exception.

Please note: Notification about drugs that are removed from the market due to safety reasons or due to the plan's determination that they are non-Part D drugs will not be sent within 60 days of removal from the market.

Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Please contact BCBSNC for details.

Blue Cross Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC is a Medicare-approved Part D sponsor. BCBSNC does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All BCBSNC items and services are available to all eligible beneficiaries in the service area.

Limitations, copayments, and restrictions may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium.

If you would like Medicare Advantage or Part D documents in a different language or format, or your coverage has ended and you need proof of coverage or a Certification of Health Insurance Coverage, you can call us 7 days a week, 8a.m. to 8 p.m.

®, 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 10/01/2012.

Y0079_5875 CMS Approved 10012012