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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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Blue Medicare PPO 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
    • Drugs used to treat sexual or erectile dysfunction
    • Drugs that are not Food and 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.)
  • 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 Option - In the coverage gap, you pay only a copayment for Tier 1 preferred generics and 65% coinsurance for all other generics. Your coinsurance for approved brand-name drugs is 45%.
  • Standard Drug Option - In the coverage gap, you pay 65% coinsurance for all generics. Your coinsurance for approved brand-name drugs is 45%.
  • 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 (Non-Preferred 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 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, 2014, the claim must be received no later than January 31, 2017. Claims received after this time frame will not be eligible for coverage.

Important Legal Information and Disclaimers

The information on this page is current as of 10/1/2015.

Y0079_7170 CMS Pending