The formulary, or list of covered drugs, for Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM 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, Medicare Plus Blue PFFSSM 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:
Barbiturates
Benzodiazepines
Fertility drugs
Drugs for weight loss or weight gain
Drugs for hair growth
Over-the-counter drugs
Prescription vitamins (except prenatal vitamins and fluoride preparations)
Drugs for Erectile Dysfunction
Drug coverage determinations and exceptions are further explained in your Evidence of Coverage and below (reference Chapter 9 for Medicare Plus Blue PPOSM and Medicare Plus Blue PFFSSM 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 Customer Service number on the back of your Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM 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 Customer Service number on the back of your Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM 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 Customer Service number on the back of your Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM or Prescription Blue PDPSM ID card. For expedited requests outside of regular business hours, call the Customer Service number on the back of your Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM or Prescription Blue PDPSM ID card and follow the instructions provided.
Fax: 866-601-4428
Writing:
Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd., MC B787
Detroit, MI 48226
Medicare Plus Blue PPOSM and Medicare Plus Blue PFFSSM are health plans with Medicare contracts. Prescription Blue PDPSM is a stand-alone prescription drug plan with a Medicare contract.
Medicare Plus Blue PPOSM Medicare Plus Blue PPOSM is available to all Medicare beneficiaries who are Michigan residents who reside within the plan's 75-county service area and are entitled to receive services under Medicare Part A and enrolled in Part B.
Medicare Plus Blue PPOSM is available in these counties: Alcona, Alger, Allegan, Alpena, Arenac, Baraga, Barry, Bay, Berrien, Branch, Calhoun, Cass, Chippewa, Clare, Clinton, Crawford, Delta, Dickinson, Eaton, Genesee, Gladwin, Gogebic, Gratiot, Hillsdale, Houghton, Huron, Ingham, Ionia, Iosco, Iron, Isabella, Jackson, Kalamazoo, Kent, Keweenaw, Lake, Lapeer, Lenawee, Livingston, Luce, Mackinac, Macomb, Manistee, Marquette, Mason, Mecosta, Menominee, Midland, Missaukee, Monroe, Montcalm, Montmorency, Muskegon, Newaygo, Oakland, Oceana, Ogemaw, Ontonagon, Osceola, Oscoda, Otsego, Ottawa, Presque Isle, Roscommon, Saginaw, Sanilac, Schoolcraft, Shiawassee, St. Clair, St. Joseph, Tuscola, Van Buren, Washtenaw, Wayne, Wexford.
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 your Medicare Plus Blue PPOSM ID card. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit bcbsm.com/medicare/search.shtml.
Medicare Plus Blue PPOSM provides reimbursement for all covered benefits regardless of whether they are received in-network, as long as they are medically necessary.
Medicare Plus Blue PFFSSM Medicare Plus Blue PFFSSM is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and enrolled in Part B.
A Medicare Advantage private fee-for-service plan works differently than a Medicare supplement plan. Your doctor or hospital can continue to treat you if it agrees to accept our terms and conditions of payment, and thus may choose not to treat you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may choose not to provide health care services to you, except in emergencies. Providers can find the plan's terms and conditions on our Web site at bcbsm.com/ma. You can also read more about how private fee-for-service plans work for you in our downloadable flyer (PDF 160K).
Prescription Blue PDPSM Prescription Blue PDPSM 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 beneficiaries enrolled in a Medicare Advantage PFFS plan that includes Medicare prescription drugs or any Medicare Advantage coordinated care (HMO or PPO) plan will be automatically disenrolled from the HMO, PPO or Medicare Advantage PFFS plan if they enroll in a prescription drug plan; and Medicare beneficiaries enrolled in a private fee-for-service plan (PFFS) that does not include Medicare prescription drug coverage, a Medicare Advantage Medicare Savings Account (MSA) plan or an 1876 Cost plan may enroll in a prescription drug plan and will not be automatically disenrolled from the PFFS, MSA or 1876 Cost plan.
Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM and Prescription Blue PDPSM
Premiums vary by county. You must continue to pay your Medicare Part B premium.
In Michigan, 86 percent of pharmacies are network pharmacies; nationwide, more than 80 percent of pharmacies are in the network, including the majority of chain pharmacies, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies (Source: 2010 Pharmacy Directory). 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. 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 Customer Service 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, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information contact the plan Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1, 2011. Please contact Blue Cross Blue Shield of Michigan for details.
In addition to enrolling through this Web site, Medicare beneficiaries may enroll in Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM or Prescription Blue PDPSM through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at 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, Medicare Plus Blue PFFSSM or Prescription Blue PDPSM during specific times of the year. To learn more about enrollment periods, please contact Customer Service.
This document is available in alternate formats or languages. For more information, call 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704.
Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM and Prescription Blue PDPSM are issued by Blue Cross Blue Shield of Michigan, which contracts with the federal government. Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM and Prescription Blue PDP'sSM contracts with CMS are renewed annually and the availability of coverage beyond the end of the contract year is not guaranteed.
You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:
1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week;
The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778; or
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