Blue MedicareRx – Answers to your Questions.
Some employers have chosen to offer Blue MedicareRx group Medicare Part D prescription drug coverage to their Medicare-eligible employees. If your employer is one of these, the group benefits administrator is your source for answers to group-specific questions such as these:
- Am I eligible for coverage under my group’s retiree plan(s)?
- When and how do I sign up?
- What are my group’s benefits?
- Does my group use a custom list of preferred drugs (formulary) or does it use a standard list?
How do I find out if my drugs are covered?
What do I do if one of my drugs is not listed on the drug list/formulary?
What pharmacies can I use?
What do I do if I have to get a prescription from a pharmacy that is not in the network?
I haven’t received my Blue MedicareRx identification card yet. How can I get my prescriptions?
I already have prescription drug benefits through my former employer’s retirement plan. Shouldn’t it be changed to a Medicare Part D prescription drug plan such as Blue MedicareRx?
Who qualifies for special assistance in paying the yearly deductible, prescription drug copayments, and monthly drug plan premiums?
What are my protections in this plan?
Q. How do I find out if my drugs are covered?
A. As long as you are online, the easiest way is to use our online drug finder. It will tell you whether a drug is covered and, for copayment plans, it will list the drug “tier” (payment level). Both complete and abridged formularies (lists of covered drugs) can be accessed online. These formularies may be available as printed booklets from your group benefits administrator. You may also call Customer Service at (877) 838-3875 (TTY users call (800) 693-3816) to ask about coverage for specific drugs. NOTE: If your group has a custom formulary, please obtain a drug list from your group benefits administrator.
Q. What do I do if one of my drugs is not listed on the drug list/formulary?
A. Call Customer Service. If it confirms that the drug is not covered, you have three options:
- You can ask your doctor if you can switch to another drug that is covered by us. If you would like to give your doctor a list of covered drugs that are used to treat similar medical conditions, please contact Customer Service.
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You can ask us to make an exception to cover your drug. See Section 6 in your Evidence of Coverage booklet to learn more about how to request an exception.
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You can pay out-of-pocket for the drug and request that the plan reimburse you by requesting a formulary exception. This does not obligate the plan to reimburse you if the exception request is not approved. See Section 6 in your Evidence of Coverage booklet for more information on how to request an appeal.
If you recently joined this Plan and learned that we do not cover a drug you were taking when you joined our plan, you may be able to get a one-time fill of that prescription. You can get a one-time fill of the non-covered drug if one of the following applies:
- You didn’t know that your drug wasn’t covered by this Plan, or
- You knew it wasn’t covered but you didn’t know that you could request an exception to the Plan’s formulary.
After your one-time fill, you can ask Customer Service if we cover another drug to treat your medical condition. If we cover another drug, you can ask your doctor if this drug is an option for your treatment. You can also file a request for an exception to our formulary.
Q. What pharmacies can I use?
A. Blue MedicareRx has an extensive network of pharmacies: 50,000 across the country. Our mail-order pharmacy from Prime Therapeutics can reduce your costs for 90-day prescriptions of maintenance drugs. This savings is matched at in-network “preferred” pharmacies—Target, Safeway, Wal-Mart, Albertson’s, Kroger’s and their affiliates. With few exceptions, you must use network pharmacies to receive Blue MedicareRx benefits.
Q. What do I do if I have to get a prescription from a pharmacy that is not in the network?
A. Keep your receipts and any paperwork so that you can file a “paper claim.” A claim form will be available online. Your group benefit administrator should also have claim forms.
Q. I haven’t received my Blue MedicareRx identification card yet. How can I get my prescriptions?
A. Members will receive a personalized acknowledgement letter with your
unique identification number. If you haven't received your ID card,
take this letter to the pharmacy. The pharmacy will use the information
on this letter to verify your benefits. Or you can call Blue MedicareRx
Customer Service and we'll assist in getting your prescription filled.
Q. I already have prescription drug benefits through my former employer’s retirement plan. Shouldn’t it be changed to a Medicare Part D prescription drug plan such as Blue MedicareRx?
A. Not necessarily. Your current retiree drug coverage may be “creditable” (coverage with equal or greater value than Medicare standard prescription drug coverage). If so, you can keep your “creditable” coverage and avoid a late enrollment penalty should you later enroll in a Part D prescription drug plan for individuals. The organization offering your current coverage, such as your former employer or union or the insurance company they hired, will tell you whether or not your current coverage is “creditable.”
Q. Who qualifies for special assistance in paying the yearly deductible, prescription drug copayments, and monthly drug plan premiums?
A. Assistance is available for those with limited income and resources. Your eligibility is determined by your annual income AND your resources including savings and stock—but not your home or car. If you qualify and both apply for assistance and enroll in Blue MedicareRx, Medicare will tell us how much assistance you are receiving, and we will send you information on the amount you will pay.
For more information and an application form for assistance, please select this link to the “Help with Medicare Prescription Drug Plan Costs” page on the Social Security Web Site. You may also call these resources to see if you might qualify for assistance:
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Medicare: (800) MEDICARE (633-4227), 24 hours a day, 7 days a week, (TTY users call (877) 486-2048)
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your State Medicaid Office
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Social Security Administration: (800) 772-1213 (TTY/TDD users call (800) 325-0778), between 7 a.m. and 7 p.m., Monday through Friday
Q. What are my protections in this plan?
A. All Medicare Prescription Drug Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Prescription Drug Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare prescription drug coverage in your area.
If Blue MedicareRx ever denies coverage for your prescription drugs, we will explain our decision to you. You always have the right to appeal and ask us to review the claim that was denied. In addition, if your physician prescribes a drug that is not on our formulary, is not a preferred drug or is subject to additional utilization rules, you may ask us to make a coverage exception.
* By clicking this link, you will be leaving the Part-D Plan-specific Web pages.
** Per a GEO Access analysis conducted by Prime Therapeutics. 10/7/2005.
Last updated 12/19/2005 - S5715-MRK-NMWebsite
