Drug coverage determination and exception

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The formulary, or list of covered drugs, for Medicare Plus Blue PPOSM and Prescription Blue PDPSM, includes medications selected to meet members' needs. However, if you and your physician feel you need a drug that is not included on the Medicare Plus Blue PPOSM and Prescription Blue PDPSM formulary, but it is a covered Medicare Part D drug, you may ask us for a coverage determination or an exception.

Determination form

Please note that you may not ask for a coverage determination or exception for medications not covered under Medicare Part D such as:

Drug coverage determinations and exceptions are further explained in your Evidence of Coverage and below (reference Chapter 5 for Medicare Plus Blue PPOSM members; Chapter 3 for Prescription Blue PDPSM members).

What are coverage determinations and tier requests?

A coverage determination is a decision about whether or not to provide or pay for Medicare Part D drugs, and what your share of the cost will be. Coverage determinations include exception requests. You have the right to ask us for an exception if you believe you need a drug that is not on our formulary, believe you should get a drug at a lower copayment, or are requesting an exception to the step therapy or prior authorization requirement for a drug.

You may ask for a tier exception for Tier 2 and 4 drugs only. This means you can ask that your copay for your Tier 2 drug be reduced to the copay of a Tier 1 drug and Tier 4 drug be reduced to the copay of a Tier 3 drug when your doctor can provide clinical information that indicates you cannot take any other formulary drug option for your condition. You cannot ask for a tiering exception for a Tier 5 (Specialty) drug. Additionally, you cannot obtain a brand-name drug at the copayment that applies to generic drugs.

If you request a tier exception your doctor must provide a statement to support your request.

You can call us to request a coverage determination by telephone or you may submit the Coverage Determination Form by fax or mail.

Fast, or expedited, vs. standard coverage determination for prescription drugs

A decision about whether we will cover a Medicare Part D prescription drug can be a "standard" coverage determination that is made within the standard time frame (typically within 72 hours; see below), or it can be a "fast" coverage determination that is made more quickly (typically within 24 hours). For those decisions that require documentation from the prescribing physician the time frame does not start until that documentation is submitted. If no documentation is submitted, the request will not be approved.

Fast, or expedited, coverage determination

A fast decision is sometimes called an "expedited coverage determination." You, your prescribing physician or authorized representative can ask for a fast decision. If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast review. (Fast decisions apply only to requests for Medicare Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Medicare Part D drug that you already received.)

You or your appointed representative can ask us to give you a fast decision (rather than a standard decision) by calling the Member Services number on the back of your Medicare Plus Blue PPOSM or Prescription Blue PDPSM identification card. Your doctor can ask us to give a fast decision by calling the Pharmacy Services Clinical Help Desk at 1-800-437-3803, Option 1, from 8 a.m. to 8 p.m. Monday through Friday. TTY users call 711.

Standard Coverage Determination

To ask for a standard decision, you or your appointed representative can contact us by calling the Member Services number on the back of your Medicare Plus Blue PPOSM or Prescription Blue PDPSM identification card. Your doctor can ask us to give a fast decision by calling the Pharmacy Services Clinical Help Desk at 1-800-437-3803, Option 1, from 8 a.m. to 8 p.m. Monday through Thursday, Friday from 8 a.m. to 6 p.m. TTY users call 1-800-649-3777.

Contact information

Phone:

Call the Member Services number on the back of your Medicare Plus Blue PPOSM or Prescription Blue PDPSM ID card. For expedited requests outside of regular business hours, call the Member Services number on the back of your Medicare Plus Blue PPOSM or Prescription Blue PDPSM ID card and follow the instructions provided.

Fax:

1-866-601-4428

Write:

Blue Cross Blue Shield of Michigan
Pharmacy Help Desk — C303
P.O. Box 807
Southfield, MI 48037

Email:

dramspriorauthmedicared@bcbsm.com

Instructions and form

Instructions on how to complete a Request for Medicare Prescription Drug Coverage Determination Form

For providers:

Medicare Part D Coverage Determination Request Form (PDF)

H9572 S5584_W_Apr13BCBSMAdvWeb CMS Approved 04292013

Important information about these plans

Medicare Plus Blue PPOSM, BCN Advantage HMO-POSSM and BCN Advantage HMO FocusSM are health plans with Medicare contracts. Prescription Blue PDPSM is a stand-alone prescription drug plan with a Medicare contract.

Medicare Plus Blue PPO

Medicare Plus Blue PPO is available to all Medicare beneficiaries who are Michigan residents and are entitled to receive services under Medicare Part A and enrolled in Part B.

With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare-allowed amount and the contracted amount is lower. You may receive services from any provider who accepts Original Medicare. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit www.bcbsm.com/medicare/provdirectory.shtml.

Prescription Blue PDP

Prescription Blue PDP is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B.

Medicare Plus Blue PPO and Prescription Blue PDP

Premiums vary by county. You must continue to pay your Medicare Part B premium.

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,300 Michigan retail pharmacies, of which an estimated 86 percent are network pharmacies. Nationwide, most chain pharmacies are in our network, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies.

In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances; for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. Quantity limitation and restrictions may apply. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Member Services at 1-877-241-2583, 8 a.m. to 8 p.m. Eastern time, Monday through Friday, with weekend hours Oct. 1 through Feb. 14. TTY users call 711. Certain services available 24/7 through our automated telephone response system. TTY users call 711. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X510, Detroit, MI 48226.

If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and or copayments/coinsurance may change on Jan. 1 of each year.

Medicare beneficiaries may enroll in Medicare Plus Blue PPO, BCN Advantage HMO-POS, BCN Advantage HMO or Prescription Blue PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. BCBSM does not control Medicare's website and is not responsible for its content.

For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583. TTY users call 711. Hours are: 8 a.m. to 8 p.m. Eastern time, Monday through Friday, with weekend hours Oct. 1 through Feb. 14. TTY users call 711. Certain services available 24/7 through our automated telephone response system.

You may only enroll in Medicare Plus Blue PPO or Prescription Blue PDP during specific times of the year. To learn more about enrollment periods, contact Member Services.

BCN Advantage HMO-POS

BCN Advantage HMO-POS is available in these counties: Allegan, Barry, Bay, Calhoun, Clare, Clinton, Crawford, Eaton, Genesee, Gladwin, Grand Traverse, Gratiot, Huron, Ingham, Ionia, Isabella, Jackson, Kalamazoo, Kalkaska, Kent, Lapeer, Livingston, Macomb, Mecosta, Midland, Missaukee, Monroe, Montcalm, Muskegon, Newaygo, Oakland, Oceana, Ottawa, Roscommon, Saginaw, St. Clair, Sanilac, Shiawassee, Tuscola, Van Buren, Washtenaw and Wayne. Premiums vary by county. You must continue to pay your Medicare Part B premium.

You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Medicare nor BCN Advantage will be responsible for the costs. Out-of-network services authorized by BCN Advantage will be covered. Our point-of-service benefit allows you to get care from providers not in our network under certain conditions. If you're traveling outside of Michigan, you're covered under our point-of-service BlueCard benefit and can access out-of-network doctors, specialists or hospitals that participate with Blues plans. You may receive most plan-covered services at in-network out-of-pocket cost sharing. You may need to pay higher cost-sharing for routine care from non-network providers.

If you are enrolled in BCN Advantage ClassicSM or PrestigeSM plans, you must use a network pharmacy to access your prescription drug benefit, except under non-routine circumstances when you cannot reasonably use a network pharmacy. Our pharmacy network includes the majority of chain pharmacies, mail order through Medco Pharmacy® (now a part of the Express Scripts family of pharmacies) or Walgreens, as well as long-term care and home infusion pharmacies. For additional information on network pharmacies, call Customer Service at 1-800-450-3680, 8 a.m. to 8 p.m., seven days a week. TTY users call 711. You may also write to: BCN Advantage, 2311 Green Road, Ann Arbor, MI 48105.

BCN Advantage HMO Focus

BCN Advantage HMO Focus is available only to residents of Wayne County. You must use BCN Advantage Focus plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Medicare nor BCN Advantage will be responsible for the costs. You must continue to pay your Medicare Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. Medicare beneficiaries may also enroll in BCN Advantage through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. BCN Advantage's contract with CMS is renewed annually and the availability of coverage beyond the end of the contract year is not guaranteed. Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1 of each year.

BCN Advantage HMO Focus plan members must use a network pharmacy to access their prescription drug benefit, except under non-routine circumstances when they cannot reasonably use a network pharmacy. Our pharmacy network includes the majority of chain pharmacies, mail order through Medco Pharmacy® (now a part of the Express Scripts family of pharmacies) or Walgreens, as well as long-term care and home infusion pharmacies. For more information call the Customer Service number on the back of your ID card from 8 a.m. to 8 p.m., Monday through Friday, with weekend hours October 1 through February 14. TTY users should call 711. Certain services are available 24/7 through our automated telephone response system. You may also write to: BCN Advantage, 2311 Green Road, Ann Arbor, MI 48105.

The BCN Advantage benefit information provided on this website is not complete. Additional information should be requested before making a decision about your coverage. For full information on BCN Advantage benefits, current members should call our Customer Service department at 1-800-450-3680, from 8 a.m. to 8 p.m., seven days a week. TTY users call 711. Prospective members should call 1-877-469-2583. TTY users call 711. Hours are: 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30; 8 a.m. to 9 p.m. Eastern time, seven days a week, Oct. 1 to Feb. 14.

Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1 of each year. Contact BCN Advantage for details.

If you decide to have your BCN Advantage premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium. Medicare beneficiaries may enroll in BCN Advantage through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at medicare.gov. For more information, contact BCN Advantage at 1-877-469-2583. TTY users call 711. Hours are: 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30; 8 a.m. to 9 p.m. Eastern time, seven days a week, Oct. 1 to Feb 14.

Legacy Medigap

Legacy Medigap offers access to any hospital, doctor or other health care provider in the U.S. or its territories that accepts Medicare assignment. The plan does not require members to use a specified provider network. Legacy Medigap is a Medigap health insurance policy administered by Blue Cross Blue Shield of Michigan. Neither Blue Cross Blue Shield of Michigan nor agents authorized to sell Blue Cross Blue Shield of Michigan policies are connected with Medicare.