Blue MedicareRx (PDP)^SM Terms and Conditions

• 60-Day Formulary Change
• Conditions and Limitations
• Contract Termination
• Coverage Determination
• Determination Request
• Disenrollment
• Drug Utilization Review
• Filing a Grievance
• Fraud, Waste and Abuse
• Formulary Exceptions 
• Grievances and Appeals
• Medication Management Programs
• Plan Transition Process
• Privacy Notice
• Summary of Benefits

60-Day Formulary Change

The Blue MedicareRx (PDP) formulary is current as of this publication. A formulary is a list of covered drugs. The information is updated on a monthly basis. Once enrolled, you can call our Product Specialist at 1-877-282-3785, 8 a.m. - 8 p.m., Central time, 7 days a week. For the hearing or speech impaired, please call 1-888-844-3792.

If a medication you use is removed from the list, you will be notified at least 60 days before it is removed from the drug list.

If the Food and Drug Administration (FDA) deems a drug on the list is unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove it from our list.

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Grievances and Appeals

We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage. Please call our Product Specialist at 1-877-282-3785, 8 a.m. - 8 p.m., Central time, 7 days a week. For the hearing or speech impaired, please call 1-888-844-3792.

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 once we receive a complaint. You cannot be disenrolled or penalized in any way because you file a complaint.

A complaint will be handled as a grievance or an appeal depending on the subject of the complaint. To obtain an aggregate number of grievances, appeals, and exceptions filed with Blue MedicareRx (PDP), please call our Product Specialist at the number above. The following section briefly discusses grievances and appeals.

What is a grievance?

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with us or one of our network pharmacies that does not relate to coverage for a prescription drug. 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 get the information you need, or the cleanliness or condition of a network pharmacy.

What is an appeal?

An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

How do I file an appeal or grievance?

The links to the forms needed to file an appeal or grievance are at the end of this section, for detailed instructions on how to file an appeal or grievance, please contact our Product Specialist at 1-877-296-8194, 8 a.m. - 8 p.m., Central time, 7 days a week. For the hearing or speech impaired, please call 1-888-285-2252.

• File a Grievance*
• Appeal Form 

You may also refer to your Evidence of Coverage (EOC) that was included in your Welcome Kit.

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Coverage Determination

When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. 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 list of covered drugs (formulary) or believe you should get a drug at a lower copayment.
• If you request an exception, your doctor must provide a statement to support your request.
• You must contact us if you would like to request a coverage determination (including an exception).
• You cannot request an appeal if we have not issued a coverage determination.
  

You must contact us to request an exception. Please call our Customer Service at 1-888-844-3781, 8 a.m. - 8 p.m., Central time, 7 days a week. For the hearing or speech impaired, please call 1-888-844-3792. You may also refer to your Evidence of Coverage (EOC) that was included in your Welcome Kit.
Medicare Prescription Drug Determination Request*

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Formulary Exceptions

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 (PDP) 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 preferred brand drug, you can ask us to cover it as a generic instead. This would lower the coinsurance/copays amount you must pay for your drug.

Generally, Blue MedicareRx (PDP) 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.
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 in treating your condition.

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Conditions and Limitations

• There are limits to when and how often you can change your Medicare plan options.
• To take advantage of Blue MedicareRx (PDP), you must be entitled to Medicare Part A and/or enrolled in Part B. You must also maintain your Medicare Part A and Part B coverage by paying monthly Part B premiums, and if applicable, Part A premiums, if not otherwise paid for under Medicaid or another third party.
• Copays, coinsurance and premiums may apply.
• To receive benefits with lower copays, you must use contracted network pharmacies. We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. In this situation, you will have to pay the full cost (rather than paying just your copay) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. To learn how to submit a paper claim, please refer to the paper claims process described below.
• Blue MedicareRx (PDP) contracts with CMS are on an annual basis, therefore availability of coverage beyond the end of the current contract year is not guaranteed.

How to submit a paper claim form

When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. You may ask us to reimburse you for our share of the cost by submitting a claim to us. To do so, follow these instructions:

 

Claims must be filed no later than three years after the date of purchase. Claims not filed within three years from the date of purchase will not be eligible for reimbursement.

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Drug Utilization Review

Blue MedicareRx (PDP) 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 prescribing 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 (PDP) 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 (PDP) identifies a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Medication Management Programs

Blue MedicareRx (PDP) offers medication management programs for members who have multiple chronic conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for Blue MedicareRx (PDP) by a team of pharmacists and doctors. We use these medication management programs to help us provide better care for our members. For example, these programs help us to make sure that our members are using appropriate drugs to treat their medical conditions and help us to identify possible medication errors. Please note that these programs may have limited eligibility criteria and are not considered a benefit under Blue MedicareRx (PDP).
To learn more about our medication management programs, or to join a program, contact our Product Specialist at 1-877-282-3785, 8 a.m. - 8 p.m., Central time, seven days a week. For the hearing or speech impaired, please call 1-888-844-3792.

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Plan Transition Process

• If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days).
• We will cover more than one refill of these drugs for the first 90 days you are a member of our plan.
• If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

If you experience an unplanned transition from one treatment setting to another, like entering a long-term care facility, you may be taking drugs that are not on our formulary but require prior authorization, step therapy or quantity limits. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are in a different treatment setting.

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Disenrollment

"Disenrollment" from Blue MedicareRx (PDP) means ending your membership with us. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice). We are not allowed to ask you to leave the Plan because of your health.

Below is a brief description of each type of disenrollment:

Voluntary Disenrollment

A member may disenroll from Blue MedicareRx (PDP) for any reason during one of the election periods by doing the following:

• Providing a signed written notice to Blue MedicareRx (PDP), or through their employer, where applicable
• By calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. For the hearing or speech impaired, please call 1-877-486-2048.

If you disenroll in Blue MedicareRx (PDP), you may join another Medicare Prescription Drug Plan to get prescription drug coverage. You also have the choice of joining a Medicare Advantage Plan or a Medicare Cost Plan with prescription drug coverage, if this type of plan is available in your area, if they are accepting new members, and if you meet the eligibility requirements of the plan.

If you leave Blue MedicareRx (PDP), it takes some time for your prescription drug coverage to end and your new prescription drug coverage to begin. Please call a Product Specialist at 1-877-282-3785, 8 a.m. - 8 p.m., Central time, 7 days a week. For the hearing or speech impaired, please call 1-888-844-3792.

Involuntary Disenrollment

HCSC Insurance Services Company (HISC) must disenroll an individual from Blue MedicareRx (PDP) in the following cases:

• A change in residence making the individual ineligible to be an enrollee of Blue MedicareRx (PDP).
• The individual loses entitlement to Medicare.
• The individual dies.
• The Blue MedicareRx (PDP) contract is terminated or Blue Cross and Blue Shield of Oklahoma discontinues offering Blue MedicareRx (PDP) in any portion of the area where it had previously been available.
• The individual materially misrepresents information to HISC regarding reimbursement for third-party coverage.

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Fraud, Waste, and Abuse

Health care fraud - a problem that amounts to an estimated $60 billion annually^†† - can be reduced, and in some cases, even prevented through heightened awareness of what may count as fraudulent conduct. Blue Cross and Blue Shield of Oklahoma (BCBSOK) is committed to detecting and halting health care fraud, waste and abuse (fraud) through its Special Investigations Department (SID). This department is dedicated to protecting you and your prescription drug plan. However, BCBSOK needs your help to identify and prevent health care fraud.

As a participant in the Blue MedicareRx (PDP) prescription drug plan, there are a number of things you can do to help identify and prevent health care fraud. Before discussing those things, however, there are some guidelines you should know and remember about the Medicare Part D program. Please be aware that individuals working with Medicare are not permitted to:

• Come to your home uninvited to sell or endorse any Medicare-related product
• Enroll you into a drug plan over the telephone unless you initiate the call
• Ask for bank account or other personal information over the phone
• Ask for payments over the phone or internet
• Seek premium payments upfront or before you have been billed
• Call a beneficiary after he or she has asked not to receive additional calls
• Call before 8 a.m. or after 9 p.m.
• Offer a gift worth more than $15 or a cash payment as an incentive to enroll in a Part D plan

With these guidelines in mind, here are some fraud schemes and other areas where fraud may arise in connection with your Blue MedicareRx (PDP) plan and what you can do to help.

$299/$379 Scam

Since the Medicare Part D enrollment period began, anti-fraud agencies have received a growing number of complaints in connection with what has become known as the "$299 Ring." In this scam, an individual claiming to be associated with Medicare will call your home and offer to help enroll you in a Part D plan for a "small fee," generally $299 or $379. The caller will then ask for personal information, such as your social security, bank account, or credit card number. If you receive such a call, do not give out any information and do not agree to withdraw funds from your checking account. Tell the caller not to contact you again and hang up the phone. Remember, legitimate Medicare representatives 1) are not permitted to ask you for any personal information if they initiate the call and 2) cannot solicit or take payment information over the phone.

Inappropriate Billing

When you use your Blue MedicareRx (PDP) plan to get prescription drugs, you should only be charged for the specific drug you have received. You should not be charged for non-existent prescriptions or orders you never picked up. Each time you receive an explanation of benefits (EOB) form, review the form to check that the prescriptions listed match those you actually filled and picked up. Your pharmacist should never charge you for a brand name drug when you were given a generic alternative, or bill a drug that is not covered by your plan as a covered item.

Falsification of True Out-of-Pocket (TrOOP)

True out-of-pocket (TrOOP) costs are the expenses that count toward the annual Medicare drug plan threshold for each year. If you are unsure whether or not an expense should be counted toward your TrOOP, contact a BCBSOK Product Specialist at 1-877-282-3785, 8 a.m. - 8 p.m., Central time, 7 days a week. For the hearing or speech impaired, please call 1-888-844-3792 for clarification. Only those expenses relating to your health and medical costs should be counted as your TrOOP; you cannot include the costs of a spouse or friend as part of your own expenses. You should not attempt to manipulate your TrOOP costs in order to bridge the coverage gap and reach catastrophic coverage before you are truly eligible. This may be viewed as fraud and could lead to an investigation.

Drug Shorting

On some occasions, your pharmacist may be unable to fill your entire prescription at one time. If this happens, your pharmacist should inform you and make arrangements to provide you with the remaining amount. In such cases, you will be responsible for only one copay. However, if your pharmacist intentionally provides less than the prescribed amount without letting you know or fails to provide you with the balance of a partially filled prescription, but bills your Blue MedicareRx (PDP) plan for the full amount, he or she may have committed fraud.

Prescription Splitting

When you provide your pharmacist with a single prescription form, you should receive your prescription in one order and only be billed once. Your pharmacist should only receive one dispensing fee each time a prescription is filled or refilled and therefore should not split drugs into two or more separately billed orders.

Improper Coordination of Benefits

When using your Blue MedicareRx (PDP) plan, you should always inform your doctor or pharmacist of any additional insurance coverage you have. This will help your doctor know which plan to bill in order to comply with your coverage guidelines. You should not try to conceal information about additional coverage in the hopes of lowering the payments you personally make because this might be viewed as an attempt to commit fraud.

Inappropriate Duplicate Coverage

If you are covered by both the Blue MedicareRx (PDP) plan and a Medicare Part B (medical insurance) plan, there may be additional issues that arise because of your duplicate coverage. When you receive your explanation of benefits (EOB) forms, you should check to ensure that your doctor or pharmacist has not billed both plans for the same prescription order. Additionally, if you pick up a prescription from your pharmacy which you take to an office visit for your doctor to administer, you should consult your EOB to make sure your doctor has only billed your plan for the administration of the drug and not for the cost of the drug. In this situation, your pharmacy should be the only one charging you for the cost of the drug.

If you are covered by multiple plans and are unsure which plan should be billed in any situation, call the BCBSOK customer service number to be sure that you, your doctor, and your pharmacist submit your claims to the appropriate plan.
In addition to the specific schemes and issues above, fraud may include:

• Someone asking you to sell your Medicare prescription drug card
• Someone offering you cash or a gift worth more than $15 to sign up for a plan
• Someone asking you to get drugs for them with your Medicare prescription card
• An individual calling your home to enroll you over the phone or to ask for payments

How You Can Help

Treat your health insurance card with the same level of care and security given to a debit or credit card: if your insurance card, social security number, or other personal information is ever lost or stolen, immediately report the matter to BCBSOK's Product Specialist at 1-877-282-3785, 8 a.m. - 8 p.m., Central time, 7 days a week. For the hearing or speech impaired, please call 1-888-844-3792.

In addition, pay close attention to all explanation of benefits (EOB) forms and be sure to review each form to ensure that you have been properly charged for any costs associated with your Blue MedicareRx (PDP) plan. If you need help reviewing your EOBs, seek the assistance of a family member or trusted friend.

How to Report Fraud

If you believe that you have been the victim of fraud in connection with your Blue MedicareRx (PDP) plan, report any suspicious activities to the Special Investigations Department's Fraud Hotline at 1-800-543-0867. You can also report fraud online. We look forward to working with you to fight fraud.

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Contract Termination

Blue MedicareRx (PDP) agrees to stay in the program for a full year at a time. Each year, the plan decides whether or not to continue offering prescription drug coverage for the following year. Should we decide not to continue offering Blue MedicareRx (PDP), we will send you a letter explaining your options for Medicare prescription drug coverage in your area. Your Medicare coverage is not affected.

Benefits, formulary, pharmacy, network premium and/or copayments/coinsurance may change on January 1, 2010. Please contact Blue MedicareRx (PDP) for more details.

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Privacy Notice

Privacy Notice 

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Benefit Summary

Benefit Summary 

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* By clicking this link you will leave the Blue MedicareRx (PDP) Web site.

^†† www.nhcaa.org

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Last updated 09/15/09 - S5566_WEB_OK_PDP
CMS Approved 11/19/2009