A transition process has been established for new enrollees of Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx whose current drug therapies are not included on the plan's Part D formulary and current enrollees affected by formulary changes. Generally, temporary supplies of non-formulary medication are not covered by these plans, but overrides can be made during the transition period. The temporary supply will provide additional time for you to seek a formulary alternative or to complete an exception request.1
As a new member in our plan, you may currently be taking drugs that are not on our formulary or are on our formulary but your ability to get them is limited. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you may be eligible to receive an initial 30 day temporary supply of the drug anytime during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover a temporary 30 day supply unless you have a prescription written for fewer days in which case we will allow multiple fills to provide up to a total of 30 days of medication when you go to a network pharmacy. After your first 30 day transition supply, we may not continue to pay for these drugs under the transition policy. You will receive a written notice to remind you to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request a formulary exception.
If a new member is a resident of a long-term care facility (like a nursing home) we will cover a temporary 91 to 98 day supply consistent with the dispensing increment with refills provided, if needed, unless a lesser amount is actually prescribed by the ordering provider. If you need a drug that is not on our formulary or your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug unless you have a prescription for fewer days with refills provided up to a total of 31 days of medication while you pursue a formulary exception.
As a continuing/current member in the plan, you will receive your Annual Notice Of Change (ANOC) by September 30th. You may notice that a formulary medication which you are currently taking is either not on the upcoming year's formulary or its cost sharing or coverage is limited in the upcoming year.
In this case, we will provide for a transition period consistent with the above transition process for new enrollees.
For enrollees requesting temporary coverage for a non-covered medication because they are in transition, the plan will facilitate the request for coverage of a temporary supply. These types of requests may originate from an enrollee being unaware of a change in prescription drug coverage to a Part D plan, a change to Part D coverage resulting from a change in health care delivery setting, or a delay in attaining coverage for a non-formulary drug during Part D plan processing that requires time to gather the necessary information to determine coverage eligibility (e.g., formulary exceptions, or prior authorization).
If you have any questions about our transition policy or need help asking for a formulary exception, call the Customer Services number on the back of your card seven days a week 8am to 8pm.
1 Formulary network may change at any time. You will receive notice when necessary.
The information on this page is current as of 10/1/2015.
Y0079_7169 CMS Approved 11102015