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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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Transition process
What is the transition process?

BCBSNC has established a transition process for new enrollees whose current drug therapies are not included in the Blue Medicare Rx's formulary. Generally, temporary supplies of noncovered or nonformulary medications are not covered by these plans, but overrides for certain medications can be made during the transition period. The transition medication supply will provide additional time for you to seek a formulary alternative or to complete an exception request.

When does the transition process apply?

A temporary supply of certain noncovered or nonformulary medications may be covered during a transition period for particular scenarios including, but not limited to the following:

  • The initial transition of beneficiaries to the Medicare prescription drug benefit on January 1, 2006
  • The transition of new enrollees during the plan year after the initial implementation of the program
  • The transition of individuals who change plans during plan enrollment periods
  • The transition of enrollees back into their Blue Medicare Rx plan after having been covered in another setting or under another plan (e.g., individuals who enter long-term care facilities from hospitals or enter an ambulatory setting from a hospital)
How do I get a transition supply of a noncovered medication?

We have already identified a number of nonformulary drugs that qualify for automatic transition supplies. These drugs are for treating conditions where a break in current drug therapy could have an adverse affect on your health. If you are currently taking one of these drugs, the pharmacy will fill your prescription for a one-time, 30-day supply after your Plan effective date. You will receive notification that you were dispensed a noncovered or nonformulary medication and the process that must be followed by your provider to request authorization for continued coverage.

During this 30-day period you will need to:
  • Contact your prescribing provider to find out which formulary drugs may be substituted, and/or
  • Contact BCBSNC (this contact can be made by you, your authorized representative or your prescribing provider) and request an "Exception." We will make a determination about whether we will cover your drug, even though it is not on the plan formulary.

For residents of long-term care facilities, who are on noncovered medications, we will provide coverage for a temporary "first fill" supply order for at least a 90- to 180-day supply of medication prescribed by the attending physician until an appropriate arrangement can be made between the facility, the attending physician, and the long-term care pharmacy, on behalf of resident.

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 and Blue Shield of North Carolina is an HMO and PPO plan with a Medicare contract. Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal. Blue Cross and Blue Shield of North Carolina 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 Blue Cross and Blue Shield of North Carolina 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.

Blue Medicare HMO:
1-888-310-4110 (TDD/TYY 1-888-451-9957)
Blue Medicare PPO:
1-877-494-7647 (TDD/TYY 1-888-451-9957)
Blue Medicare Rx (PDP):
1-888-247-4142 (TDD/TYY 1-888-247-4145)

®, 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 10/01/2011.

Y0079_5325 CMS Approved 10192011