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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.

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 9 for Medicare Plus Blue PPOSM members; Chapter 7 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 3 and 5 drugs only. This means you can ask that your copay for your Tier 3 and 5 drugs be reduced to the copay of a Tier 2 drug when your doctor can provide clinical information that indicates you can not take any other formulary drug option for your condition. You cannot ask for a tiering exception for a drug in the Specialty tier. 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. TTY users should call 1-800-649-3777 from 8 a.m. to 7 p.m. Monday through Friday.

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. TTY users should call 1-800-649-3777 from 8 a.m. to 7 p.m. Monday through Friday.

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

Writing:

Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd., MC B787
Detroit, MI 48226

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_BCBSMAdvantageWebR1 CMSApproved 05242011

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to seventy-five (75) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about the Extra Help program, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days per week. TTY users should call 1-877-486-2048.

Important information about these plans

Medicare Plus Blue PPOSM is a health plan with a Medicare contract. 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 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 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X435, 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 herein is a brief summary, not a comprehensive 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, 2013.

Medicare beneficiaries may enroll in Medicare Plus Blue PPO, BCN Advantage HMO-POS or Prescription Blue PDP 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 8 p.m. seven days a week. TTY users should call 1-800-481-8704.

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