Grievances, Appeals & Exceptions
60 Day Formulary Change
Formulary Exceptions
Conditions & Limitations
Drug Utilization Review
Medical Therapy Management
Disenrollment
Contract Termination
Privacy Notice
Summary of Benefits
Evidence of Coverage
Grievances, Appeals & Exceptions
If you have questions, concerns, or problems related to your covered services or the care you receive. Please call Customer Service immediately at the number listed on your Member ID Card.
Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint, and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from Blue MedicareRx or penalized in any way if you make a complaint.
An “appeal” is the type of complaint you make when you want us to reconsider and change a decision we have made about what prescription drug benefits are covered for you or what we will pay for a prescription drug. For example, if we refuse to cover or pay for a prescription drug you think we should cover, you can file an appeal. If Blue MedicareRx refuses to give you a prescription drug you think should be covered, you can file an appeal. If Blue MedicareRx reduces or cuts back on the prescription drugs you have been receiving, you can file an appeal. If you think we are stopping your prescription drug coverage too soon, you can file an appeal.
A “grievance” is the type of complaint you make if you have any other type of problem with Blue MedicareRx or one of our network pharmacies. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or getting the information you need, or the cleanliness or condition of a network pharmacy.
You need to file your appeal within 60 calendar days from the date included on the notice of our initial decision. We can give you more time if you have a good reason for missing the deadline. To file a "standard" appeal or get information on the aggregate number of the Plan's grievances, appeals, and exceptions. Please write to us at the same address which is given below.
Blue MedicareRx
Attn: Appeals Department
2901 Kinwest Pkwy., Bldg. B
Irving, TX 75063
Fax - 800-706-5236
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60 Day Formulary Change
The Blue MedicareRx drug list is current as of this publication. The information is updated on a monthly basis. Once enrolled, you can call the Customer Service number on your Member ID card to obtain additional information on any changes to the Blue MedicareRx drug list. If a medication is removed from the list, you will be notified at least 60 days before it is removed from the drug list. We will also update this information, along with any drugs added to the formulary, on this website. (If the FDA deems a drug on the list is unsafe or the drug's manufacturer removes the drug from the market, we will immediately eliminate it from our list.)
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Formulary Exceptions
How Can I Request An Exception To Blue MedicareRx’s Formulary?
You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Blue MedicareRx limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
- You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a Other brand/Tier 3 drug, you can ask us to cover it as a generic/Tier 1 instead. This would lower the coinsurance copayment amount you must pay for your drug.
Generally, Blue MedicareRx will only approve your request for an exception if the alternative drugs included on the plan’s formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects. In most circumstances, if we do approve your request for an exception, the exception is good for the rest of the year.
Once an exception request is approved, it is valid for the remainder of the plan year so long as your physician continues to prescribe the drug for you and it continues to be safe and effective for treating your condition.
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Conditions & Limitations
Beginning January 1, 2006, there are limits to when and how often you can change your Medicare plan options. To take advantage of the new Prescription Drug Coverage, you must be eligible for Medicare Part A and Part B. You must also maintain your Medicare Part A and Part B coverage by paying Part B premiums, and if applicable, Part A premiums, if not otherwise paid for under Medicaid or another third party. Co-pays and premiums may apply.
To receive benefits, you must see contracted network providers and pharmacies.We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.
Blue MedicareRx's contract with CMS is renewed annually, therefore availability of coverage beyond the end of the current contract year is not guaranteed.
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Quality Assurance Policies & Procedures Drug Utilization Review
Blue MedicareRx conducts drug utilization reviews for all of our members to make sure that you are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe 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, Blue MedicareRx looks for medication problems such as:
- Possible medication errors
- Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
- Drugs that are inappropriate because of your age or gender
- Possible harmful interactions between drugs you are taking
- Drug allergies
- Drug dosage errors
If Blue MedicareRx identifies a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
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Medical Therapy Management
MTM is a special program for members with complex medication therapy. You may be invited to participate in a MTM program designed to support your specific health and pharmacy needs. You may decide not to participate, but we recommend that you take full advantage of this covered service if you are selected. If you have any questions concerning our MTM Program or would like additional information, contact Blue MedicareRx.
(877) 838-3875
(800) 693-3816 TTY
Monday through Friday 6:00 a.m. to 6:00 p.m.
Disenrollment
“Disenrollment” from Blue MedicareRx means ending your membership with us. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice). For example, you would have to leave Blue MedicareRx if you move out of our geographic service area or if Blue MedicareRx no longer offers prescription drug coverage. We are not allowed to ask you to leave the Plan because of your health.
If you leave Blue MedicareRx, it takes some time for your prescription drug coverage to end and your new prescription drug coverage to begin. Enrollment takes place November 15 through December 31 of every year. Enrollment is generally for the calendar year. In certain cases, such as if you move or enter a nursing home, you can disenroll from your plan at other times. After you request to disenroll, we will let you know, in writing, the date your coverage ends. If you don’t get a letter, call Customer Service and ask for the date.
In general, you may only disenroll or switch prescription drug plans under certain circumstances. You can switch your Prescription Drug Plan during the following periods:
- The initial enrollment period for prescription drug coverage is the period during which an individual is first eligible to enroll in a Prescription Drug Plan.
- In 2005: An individual who becomes eligible for prescription drug coverage prior to January 31, 2006, has an initial enrollment period from November 15, 2005, through May 15, 2006.
- February 2006: An individual who becomes eligible for prescription drug coverage in February 2006 has an initial enrollment period from November 15, 2005, through May 31, 2006.
- After March 2006: An individual who becomes eligible for prescription drug coverage after March 2006 has an initial enrollment period that begins 3 months before the month the individual becomes eligible for Medicare Part A and ends 3 months after the first month of eligibility.
- If you join a Prescription Drug Plan in 2005 (for coverage year 2006), your effective date of coverage will be January 1, 2006. If you join a Prescription Drug Plan after January 1, 2006, your coverage will be effective on the first day of the month after the month in which you join. For example, if you join on April 10th, your effective coverage date will be May 1st.
You will have to pay a late enrollment fee if your initial enrollment period ends, and for a period of 63 days or longer if you:
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were eligible for prescription drug coverage,
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did not have credible prescription drug coverage, and
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were not enrolled in a Prescription Drug Plan or Medicare Advantage Prescription Drug Plan.
If you have a Medigap (Medicare Supplement) Policy with prescription drug coverage, you should receive a letter in the fall of 2005 from your Medigap issuer explaining your options and explaining how the removal of drug coverage from your Medigap plan will affect your premiums. If you enroll in a Prescription Drug Plan during the initial enrollment period (November 15, 2005 through May 15, 2006), you will also be guaranteed the right to switch to a different Medigap plan without drug coverage from the same issuer that sold you your Medigap policy with the drug coverage. If you do not receive this letter, contact the issuer of your Medigap policy.
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Contract Termination
Blue MedicareRx's contract with CMS is renewed annually, therefore availability of coverage beyond the end of the current contract year is not guaranteed.
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Privacy Notice (Coming Soon)
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* 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
