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Blue Medicare HMO Blue Medicare PPO

Provider resources and information

Transition process

Blue Medicare HMO and Blue Medicare PPO plans have established a transition process for new enrollees whose current drug therapies are not included in the Medicare Prescription Drug Plan formulary. Generally, temporary supplies of non-formulary medication are not covered by these plans, but overrides can be made during the transition period. The transition medication supply will provide additional time for members and providers to seek a formulary alternative or to complete an exception request.

When does the transition process apply?
A temporary supply of medication 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.
  • 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 Medicare Part D 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 non-covered medication?

Blue Medicare HMO and Blue Medicare PPO have already identified a number of non-formulary 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 members' health. If a member is currently taking one of these drugs, the pharmacy will fill their prescription for a one-time, 30-day supply after their Plan effective date.

During this 30-day period members will need to:

  • Contact their prescribing provider to find out which formulary drugs may be substituted, and/or
  • Contact Blue Medicare HMO or Blue Medicare PPO (this contact can be made by the member, their authorized representative or your prescribing provider) and request an "Exception". The plan will make a determination about whether they will cover the drug, even though it is not on the plan formulary.

Blue Medicare HMO and Blue Medicare PPO plans are offered by PARTNERS National Health Plans of North Carolina, Inc., a subsidiary of Blue Cross and Blue Shield of North Carolina (BCBSNC). PARTNERS is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. Plans are administered by BCBSNC. BCBSNC and PARTNERS do 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 and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association.

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