Exclusions and Limitations for 2008 Blue Medicare HMO and Blue Medicare PPO

• 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
  • Barbiturates (sleeping pills)
  • Benzodiazepines (central nervous system depressants)
  • Drugs used to treat sexual or erectile dysfunction
• Certain drugs will have maximum quantity limits.
• Certain drugs require prior authorization.
• 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 Plan Only – In the coverage gap, coverage is limited to generic drugs. (With Standard Plan, there is no drug coverage in the coverage gap.)
• 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 3 (Specialty Tier) drug to be paid at the brand or generic cost sharing level is not permissible under this plan.
• Drugs with Quantity Limitations may not be refilled until 100% of the time period for the supply has passed. For example, if the prescription is written for a supply of 10 tablets to be used in a 30-day period, then you may obtain a refill beginning on the 31st day.
• 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 PARTNERS Medicare Advantage 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 12 months of the fill date or 3 months after benefit period end date, whichever is earliest. For example, if a drug is purchased on January 31, 2008, the claim must be received no later than January 31, 2009. However, if a drug is purchased on May 31, 2008, the claim must be received no later than March 31, 2009. Claims received after this time frame will not be eligible for coverage.