Transition policy

Blue Cross Blue Shield of Michigan provides a transition process that allows members to receive a temporary supply of non-formulary drugs or to request a formulary exception on the grounds of medical necessity. This process meets the immediate needs of our members and provides sufficient time for them to work with their health care providers to switch to a therapeutically equivalent formulary medication or to complete the formulary exception process. The transition policy applies to Part D drugs that are not on BCBSM's formulary — and to Part D drugs that are on BCBSM's formulary, but require prior authorization or step therapy under the Blues' utilization management rules.

The transition policy applies to members in various settings:

Retail or mail pharmacy setting

A temporary 31-day supply (unless the prescription is written for less than a 31-day supply) of non-formulary drugs will be provided anytime during the 90-day transition period.

Long-term care setting

Multiple fills of a temporary 31-day supply (unless the prescription is written for less than a 31-day supply) will be provided during the 90-day transition period. BCBSM will honor multiple fills of non-formulary Part D drugs for up to a 93-day supply within the first 90 days of coverage in a BCBSM plan.

Level of care changes

An emergency transition supply will be provided to current long-term care enrollees who enter into a facility from another care setting. This transition supply is not limited to initial enrollment only.

Emergency supply

After the 90-day transition period expires, BCBSM will also provide a 31-day transition supply to current long-term care enrollees who require an emergency supply of a non-formulary drug. The emergency supply will be granted while the enrollee's exception or prior authorization is being processed.

The transition policy applies to the following enrollees:

The transition period begins on the enrollee's effective date of coverage under the plan. Each enrollee who receives a transition supply will be sent a written notice via first-class U.S. mail. The notice will be sent within three days of the temporary fill. The notice will include:

Formulary exception request forms will be available to members, appointed representatives and physicians via mail, fax, email and our website.

To determine the proper course of action, Medical review of non-formulary drug requests may be required for enrollees receiving a temporary supply of a Part D drug under this policy. BCBSM will work with the enrollee's physician to gather appropriate clinical history to facilitate the non-formulary drug request or the switch to a therapeutically appropriate formulary alternative.

Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a drug that Medicare excludes from coverage or a drug from an out-of-network pharmacy, unless you qualify for out-of-network access. See your Evidence of Coverage for information about excluded drugs.

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Important information about these plans

Medicare Plus Blue and Prescription Blue are PPO and PDP plans with a Medicare contract. Enrollment in Medicare Plus Blue and Prescription Blue depends on contract renewal.

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 http://www.bcbsm.com/medicare/find-a-doctor/.

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. You may enroll in only one Part D plan at a time.

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,400 Michigan retail pharmacies, representing approximately 98 percent of all Michigan 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 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30, 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 also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X521, 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 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. You may only enroll in Medicare Plus Blue PPO or Prescription Blue PDP during specific times of the year.

For more information, please contact Blue Cross Blue Shield of Michigan at 1-888-563-3307. TTY users call 711. Hours are: 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30, with weekend hours Oct. 1 through Feb. 14.

LegacySM 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.