Back to Index

Blue Medicare HMO and Blue Medicare PPO 2013 Benefit Changes

Release Date: November 2, 2012

Key Highlights of 2013 Benefit Changes

Blue Cross and Blue Shield of North Carolina (BCBSNC) members enrolled in Blue Medicare HMOSM and Blue Medicare PPOSM products will receive changes to their benefits upon their annual renewal, effective January 1, 2013.

The changes for 2013 include:

Blue Medicare HMO

  • Formulary changes to the drugs covered and restrictions that apply to coverage for certain drugs.

Blue Medicare PPO

  • Co-pay changes:
    • Primary care office visit (in-network)
    • Medicare-covered ambulatory surgery center visit
    • Medicare-covered outpatient hospital facility visit
    • Tier 1 (preferred generic) drugs
  • Medicare-covered diabetic supplies and self-management training covered at 100%.  Note:  This does not apply to therapeutic shoes or inserts.
  • Formulary changes to the drugs covered and restrictions that apply to coverage for certain drugs.

Also, as of January 1, 2013 Blue Medicare HMO and Blue Medicare PPO members will transition to a new pharmacy benefits manager (PBM), Prime Therapeutics® - the same PBM for BCBSNC’s commercial membership.  All pharmacy prior authorizations and patient medication history currently on file with Medco (our current PBM) will automatically be transferred to Prime Therapeutics (except controlled substances).  Prime will contact physicians with Blue Medicare HMO and Blue Medicare PPO members who have controlled substance prescriptions in order to have the prescription replaced. Providers should watch for replacement of fax forms for PrimeMail as they will be available via the Provider Portal at www.bcbsnc.com in the near future.

The Blue Medicare HMO and Blue Medicare PPO networks have also been expanded into seven (7) additional North Carolina counties effective 1/1/2012.  These counties include: Anson, Jones, Madison, McDowell, Mitchell, Pamlico and Vance.

It is important to always obtain the most current member identification card and to verify eligibility and benefits in advance of providing non-emergency services to Blue Medicare HMO and Blue Medicare PPO members via HealthTrio.  To find out more about how to get HealthTrio connect for your office, visit us on the Web at: http://www.bcbsnc.com/content/providers/blue-medicare-providers/electronic-commerce/index.htm.

If you have questions regarding the 2013 benefit changes for Blue Medicare HMO and Blue Medicare PPO, please contact the Blue Medicare Provider Service Line at 1.888.296.9790.