Coverage determinations for prescription drugs

When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. (Also see the description of the exceptions process.) You must contact us if you would like to request a coverage determination, including an exception. You cannot request an appeal if we have not issued a coverage determination.

The following are examples of when you may ask Blue Medicare HMO or Blue Medicare PPO for a coverage determination:

• If you are not getting a prescription drug that you believe Blue Medicare HMO or Blue Medicare PPO covers
• If you have received a Part D prescription drug that you believe Blue Medicare HMO or Blue Medicare PPO covers while you were a member, but the plan has refused to pay for the drug
• If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped and that you believe you have extenuating circumstances that should exclude you from the reduction/non-coverage
• If there is a limit on the quantity (or dose) of the drug, and you disagree with the requirement or dosage limitation
• If you bought a drug at a pharmacy that is not in the network and you want to request reimbursement for the expense

How do I make a request for a coverage determination?

To ask for a standard decision, you or your appointed representative may call Customer Service at the numbers listed on the back cover. You can also deliver a written request to Blue Medicare HMO or Blue Medicare PPO, c/o BCBSNC, 5660 University Parkway, Winston-Salem, NC 27105, Monday-Friday from 8 a.m. - 5 p.m. You may fax your request to 1-888-375-8836.

To ask for a fast decision, you, your physician, or your appointed representative may call us at the Customer Service Department at 1-888-310-4110 (For the hearing and speech impaired: 1-888-451-9957), seven days a week, 8 a.m. - 8 p.m. You can also deliver a written request to Blue Medicare HMO or Blue Medicare PPO, c/o BCBSNC, 5660 University Parkway, Winston-Salem, NC 27105, Monday-Friday from 8 a.m. - 5 p.m. You may fax your request to 1-888-375-8836. After regular business hours, you should consult with a contract pharmacy regarding your need for an emergency or temporary supply of medication until you can contact the Plan the next business day. Be sure to ask for a "fast," "expedited," or "24-hour" review. NOTE: You cannot ask for a fast decision on a request for coverage of a drug already purchased.

When will I hear back with a decision?

Generally, we must make our decision no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. If your request involves a request for an exception (including a formulary exception or an exception from utilization management rules, such as dosage or quantity limits), we must make our decision no later than 72 hours after we have received your doctor’s "supporting statement," which explains why the drug you are asking for is medically necessary.

If you are requesting an exception, you should submit your prescribing doctor's supporting statement with the request, if possible. We will give you a decision in writing about the prescription drug you have requested. You will get this notification when we make our decision under the timeframe explained above. If we do not approve your request, we must explain why and tell you of your right to appeal our decision.

If you get a fast review, we will give you our decision within 24 hours after you or your doctor ask for a fast review—sooner if your health requires. If your request involves a request for an exception, we must make our decision no later than 24 hours after we get your doctor’s "supporting statement."

Exceptions are part of the coverage determination process. You, your authorized representative, or your prescribing physician may request an exception to seek coverage of a drug that:

• Is not on the formulary
• Requires prior authorization
• Has quantity limitations

Example of an exception request:
If the Plan’s formulary does not include a drug that you or your prescribing physician feel is necessary, then you or your prescribing physician may request an exception so that you may obtain coverage of this drug. If the Plan does not grant the requested exception, then you or your prescribing physician may file an appeal.

How do I make an exception request?

You or your prescribing physician may request an exception to the coverage rules for your Medicare prescription drug plan via:

Phone:
1-888-310-4110 (TTY/TDD 1-888-451-9957)

7 days a week, 8 a.m. - 8 p.m.

Physicians should call:
(336) 774-5400 or 1-888-296-9790

Mail:
Blue Medicare HMO or Blue Medicare PPO
c/o BCBSNC
Attn: Rx Coverage Determination
P.O. Box 17509
Winston-Salem, NC 27116-7509

A specific form is not required for you to make an exception request. The request must include your prescribing physician’s statement that he/she has determined that the preferred drug either would not be as effective for you and/or would have adverse effects for you.

When will I receive a decision on my exception request?

We will review the exception request and notify both you and your prescribing physician of our decision as soon as your health requires, but no later than 72 hours from the time we receive your physician's supporting statement. Faster exception decisions are available if this 72-hour time frame could seriously harm your health or ability to function.

If the decision is not in your favor, the notice will be given by phone followed by a written notice within three business days. The notice will tell you how to pursue your appeal rights if you are dissatisfied with our decision.