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Blue Medicare HMO Blue Medicare PPO

Provider resources and information

Formulary

The Medicare prescription drug list for Blue Medicare HMO and Blue Medicare PPO is based on a preferred list of FDA-approved prescription drugs and was developed using guidelines from the federal government. The drug list includes more than 3,700 drugs, including generic, brand name and specialty drugs. Many of the most popular prescriptions are included. Certain vaccinations, insulin and insulin injection supplies are also covered. Over-the-counter drugs are not covered because they are excluded by Medicare.

Blue Medicare HMO and Blue Medicare PPO covers both brand–name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

To determine if the drugs a provider prescribes are covered by Blue Medicare HMO or Blue Medicare PPO, click the button below to search the drug list.

Drug search

Tips for using the drug list

  • Drug tiers - Drugs are assigned into three payment categories, based on usage, cost and clinical effectiveness.
  • Prior authorization and quantity limitations
    To encourage the appropriate use of prescription drugs, some quantities are limited and some drugs must be approved before Blue Medicare HMO or Blue Medicare PPO will cover them.
  • Formulary changes - The formulary for Blue Medicare HMO and Blue Medicare PPO may change from time to time. These changes may include the removal of a drug from the formulary or a change in the payment level.
  • 60-day notice – If a members’s affected by a change to the formulary, they will be notified in writing at least 60 days prior to the change.
  • Limitations and exclusions - Like most insurance coverage, Blue Medicare HMO and Blue Medicare PPO plans have some conditions and limitations.
  • If you can’t find a drug… - If providers do not find a particular drug in the formulary, Blue Medicare HMO or Blue Medicare PPO may not cover that drug. To verify whether the given drug is covered, please call Customer Service toll-free at 1-888-310-4110, 7 days a week, 8 a.m. to 8 p.m (TDD/TTY 1-888-451-9957).
  • If a particular drug is not covered - If Blue Medicare PPO or Blue Medicare HMO does not cover a particular drug, members have the right to request that an exception be made to the formulary or to request a transition supply, while the provider finds an appropriate alternative prescription.

Transition supplies and exceptions

For instructions on how to request a transition supply or an exception to the formulary, and instructions on how to appeal a decision about an exception or to file a grievance if providers are dissatisfied for any reason, please review the following documents:


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Blue Cross and Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC does not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries 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 not otherwise paid for under Medicaid or another third party. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association.

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