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Blue Medicare Rx Limitations and Exclusions

• This plan uses a prescription drug formulary. 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
  • Barbiturates (sleeping pills)
  • Drugs used to treat sexual or erectile dysfunction
• Certain drugs will have maximum quantity limits.
• Certain drugs require prior authorization.
• 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 Drug Benefit - In the Coverage Gap, Tier 1 preferred generics are covered at a copay and all other generics are covered at 21% coinsurance. Your coinsurance is 47.5% for approved brand name drugs.
• Standard Drug Benefit - In the Coverage Gap, all generics are covered at 21% coinsurance. Your coinsurance is 47.5% for approved brand name drugs.
• 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.
• Drugs with Quantity Limitations may not be refilled until 100% of the time period for the supply has passed. For example, if the prescription is written for a supply of 10 tablets to be used in a 30-day period, then you may obtain a refill beginning on the 31st day.
• 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 the Blue Medicare Rx, you must reside within North Carolina. If you are in prison, you cannot join this plan.
• After the initial enrollment period, you may not be able to switch plans until the next open enrollment period.
• If you are eligible for Part D, and don't sign up in your initial enrollment period, you may have to pay more if you sign up later, due to a Medicare late enrollment penalty.
• 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 12 months of the fill date or 3 months after benefit period end date, whichever is earliest. For example, if a drug is purchased on January 31, 2013, the claim must be received no later than January 31, 2014. However, if a drug is purchased on May 31, 2013, the claim must be received no later than March 31, 2014. Claims received after this time frame will not be eligible for coverage.
• Drugs that are not Food and Drug Administration approved.
• Certain drugs may require step therapy.
• 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.

BCBSNC is a prescription drug plan sponsor with a Medicare contract. Prescription drug coverage is not sold as a benefit of any Medicare supplement plan.

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