Drug management programs

Utilization Management

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and/or pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. Please consult your copy of our formulary or the formulary on our website for more information about these requirements and limits. The requirements for coverage or limits on certain drugs are listed as follows:

Prior Authorization:

We require you to get prior authorization (prior approval) for certain drugs. This means that your provider will need to contact us before you fill your prescription. If we don't get the necessary information to satisfy the prior authorization, we may not cover the drug.

Step Therapy:

In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

Prior Authorization and Step Therapy Criteria:

Quantity Limit Restrictions:

For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 31 tablets per 31-day supply for a formulary drug.

Generic Substitution:

When there is a generic version of a brand-name drug available, our network pharmacies may recommend and/or provide you the generic version, unless your doctor has told us that you must take the brand-name drug and we have approved this request.

You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary or on our website, or by calling Member Services. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren't able to meet the additional restriction or limit for medical necessity reasons, you or your physician may request an exception (which is a type of coverage determination). See your Evidence of Coverage for more information about how to request an exception.

Drug Utilization Review

We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

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Important information about these plans

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

Medicare Plus Blue Group PPO

With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers in the state of Michigan. 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. In the state of Michigan, your out-of-pocket costs will be lower if you choose a network provider. To find a network provider in the state of Michigan, visit www.bcbsm.com/medicare/provdirectory.shtml.

For members traveling outside of Michigan or for those members who reside permanently outside of the state of Michigan, you may obtain care from any provider that accepts Original Medicare, and in-network cost-sharing will apply for all Medical services (except durable medical equipment, prosthetics and orthotics).

Medicare Plus Blue Group PPO and Prescription Blue PDP

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,300 Michigan retail pharmacies, of which 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 the phone number listed on the back of your member ID card.

The benefit information provided is a brief summary, not a complete description of benefits. For more information, please call Member Services at 1-866-684-8216. TTY users call 711. Extended hours of operation Jan. 1 through Feb. 14 are 8 a.m. to 8 p.m. Eastern time, seven days a week. Normal hours of operation are 8:30 a.m. to 5 p.m., Eastern time, Monday through Friday.

Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on Jan. 1 of each year.

BCN Advantage HMO-POS

BCN Advantage HMO-POSSM 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, Sanilac, Saginaw, Shiawassee, St. Clair, 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 or other services. If you obtain routine care from out-of-network providers, neither Medicare nor BCN Advantage HMO-POS will be responsible for the costs.

If you are enrolled in BCN Advantage HMO-POS Option 2 or Option 3, 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. Quantity limitations and restrictions may apply. Our pharmacy network includes the majority of chain pharmacies, mail order through Medco or Walgreens, as well as long-term care and home infusion pharmacies. For additional information on network pharmacies, please call Member Services at 1-800-450-3680, 8 a.m. to 8 p.m. seven days a week. TTY users call 1-800-430-3211. You may also write to: BCN Advantage HMO-POS, P.O. Box 5184, Mail Code A103, Southfield, MI 48086-5184.

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 co-payments/co-insurance may change on Jan. 1 of each year.

If you decide to have your BCN Advantage HMO-POS 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 HMO-POS through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583, 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 through Feb. 14. TTY users call 711. To learn more about enrollment periods, please contact Member Services.