General Pharmacy Information

  • 2015 Premera Blue Cross Medicare Advantage Part D pharmacy resources

    Medications can play a significant role in your health care. The following information will help guide your decisions about medications and answer questions about your Medicare pharmacy benefits.

    Customer Service

    For assistance with pharmacy-related questions, please call Premera Blue Cross Medicare Advantage Customer Service. We will be happy to help you. We can be reached 7 days a week, 8 a.m. to 8 p.m. at 1-888-850-8526 (TTY: 711).

    Formulary (list of covered drugs)

    Premera Blue Cross Medicare Advantage Plans uses a List of Covered Drugs. This drug list is the Premera Comprehensive Formulary and is a complete list of drugs covered by Premera Blue Cross Medicare Advantage plans. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. You will get a copy of the formulary.

    For the most up-to-date list of covered drugs, please contact Customer Service.

    Formulary changes

    We may add or remove drugs from the formulary during the year.

    Generally, if you are taking a drug that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when we receive information from the FDA that a drug is no longer considered to be safe or effective.

    What if my drug is not covered?

    If your drug is not included in this formulary, call Customer Service and ask if your drug is covered.

    If you learn that Premera Blue Cross Medicare Advantage plans do not cover your drug, you can take any of the following steps:

    • Talk to your doctor about alternative drugs that are on the formulary.
    • Seek a formulary exception.

    There are several types of formulary exceptions that you can ask us to make:

    • You can ask us to cover a drug even if it's not on our formulary.
    • You can ask us to waive coverage restrictions or limits on our drug. For example, for certain drugs, we limit 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 a greater amount.

    For more information on how to request an exception, please see Part D Coverage Determinations, Exceptions, Appeals, and Grievances.

    Transition (temporary supply)

    Premera Medicare Advantage Plans wants to make your prescription transition as safe and as easy as possible. The following guide will help you.

    Current members

    Current members may be affected by changes in our Formulary (list of covered drugs) from one year to the next. Drugs currently on the plan's formulary may be removed. If this happens and you need help switching to a different drug or requesting a formulary exception, please contact Customer Service at 1-888-850-8526.

    New members

    New members may be taking a drug that is not on our formulary or has certain restrictions such as prior authorizations, 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 of membership, we will provide a 30-day fill (unless the prescription is written for less than 30 days), with multiple refills as necessary for up to a 90-day supply when you go to a network pharmacy.

    Transition for new members in a long-term care facility

    We will allow you to refill your prescription until we have provided you with a 98-day transition supply (unless the prescription is written for fewer days). We will cover more than one refill for the first 90 days of plan membership. After the first 90 days, if you need a drug that is not on our formulary or if your ability to get your drugs is limited, we will cover a 34 day emergency supply of that drug (unless the prescription is for fewer days) while you pursue a formulary exception.

    Please read our transition policy for more information.

    Pharmacies (pharmacy network)

    Search our accurate, up-to-date database to see if your pharmacy is in our network.

    Premera Blue Cross Medicare Advantage Plans have contracts with pharmacies that equal or exceed the Centers for Medicare and Medicaid (CMS) requirements for pharmacy access in your area.

    You may go to any of our network pharmacies. However, your costs may be even less for your covered drugs if you use a network pharmacy that offers preferred cost- sharing rather than a network pharmacy that offers standard cost-sharing. The directory will tell you which of the network pharmacies offer preferred cost-sharing. You can also contact Customer Service if you need help finding a network pharmacy near you.

    Find a Doctor 

    Mail-order pharmacies

    We have mail order pharmacies in our network. For certain kinds of drugs, you can use our network mail-order services. This service allows you to order a 30- to 90-day supply of the drug. Some retail pharmacies in our network also allow you to get a long term supply of certain types of drugs. To get information about filling your prescriptions by mail, please contact Customer Service.

    About out-of-network pharmacies

    We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. The circumstances when we would cover prescriptions filled at an out-of-network pharmacy are listed below. Before you fill your prescription in these situations, call Customer Service to see if there is a network pharmacy in your area where you can fill your prescription.

    • Coverage for out-of-network access of emergency drugs and some routine drugs will be provided when the member cannot access a network pharmacy and one of the following conditions exist: You are traveling outside the service area and run out or lost your covered Part D drugs, or become ill and need a covered Part D drug.
    • You are unable to obtain a covered drug in a timely manner at a network pharmacy in your service area (e.g. no access to a 24-hour/7-day-a-week network pharmacy).
    • You are unable to obtain a particular drug as it is not regularly stocked at an accessible network pharmacy or mail order pharmacy (such as an orphan or specialty drug with limited distribution).
    • The network mail-order pharmacy is unable to get the covered Part D drug to you in a timely manner, and you run out of your drug.
    • The drug is dispensed to you by an out-of-network, institution-based pharmacy while you are in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting.

    We will cover prescriptions that are filled at an out-of-network pharmacy for medical emergencies and in some routine situations for up to a 30-day supply. Drugs excluded by federal statute from the Medicare Part D formulary are not eligible for coverage even in emergency or urgent situations.

    Requesting reimbursement for a prescription drug

    If you do go to an out-of-network pharmacy for the reasons listed above, you will generally have to pay the full cost (rather than paying just coinsurance or copayment) when you fill your prescription.

    You may ask us to reimburse you for our share of the cost by submitting a paper claim. Send us your request for payment, along with your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records.

    Mail your request for payment together with any bills or receipts to us at this address:

    Premera Blue Cross Medicare Advantage Plans
    P.O. Box 4196
    Portland, OR 97208-4196

    Contact Customer Service if you have any questions on submitting a paper claim.

    You should submit a claim to us if you fill a prescription at an out-of-network pharmacy because any amount you pay for a covered Part D drug helps you qualify for catastrophic coverage. If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.

    What if my pharmacy leaves the network?

    If the pharmacy you have been using leaves the plan’s network, you will have to find a new pharmacy that is in the network. If the pharmacy you have been using stays within the network but is no longer offering preferred cost-sharing, you may want to switch to a different pharmacy. To find another network pharmacy in your area, you can get help from Customer Service or use the Find a Pharmacy tool.

    Medication Therapy Management program

    Premera Blue Cross Medicare Advantage Plans’ Medication Therapy Management (MTM) program helps ensure your medications are working to improve your health. The MTM program is a service offered by Premera Blue Cross Medicare Advantage Plans to its members and is not considered a benefit. For more details, please see the MTM page.

    Part D Coverage Determinations, Exceptions, Appeals, and Grievances

    Read more about Part D Coverage Determinations, Exceptions, Appeals, and Grievances.

    Other important information:

    Contact Us

    Sales: 888-868-7767 (TTY: 711)
    Monday through Friday
    8 a.m. to 8 p.m.
    (7 days a week, 8 a.m. to 8 p.m., Oct. 1 - Feb. 14)

    Customer Service: 888-850-8526 (TTY: 711)
    Monday through Friday
    8 a.m. to 8 p.m.
    (7 days a week, 8 a.m. to 8 p.m.)

    PO Box 4196
    Portland, OR 97208-4196

  • Extra Help

    The government subsidizes prescription drug costs for members with limited incomes. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to 100% 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 know it. For more information about this Extra Help see the LIS Premium Summary Table, contact your local Social Security office, or call 800-MEDICARE (800-633-4227), 24 hours per day, 7 days per week. TTY users should call 877-486-2048.

    Best Available Evidence

    CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information is not accurate in CMS’s systems. View the CMS Best Available Evidence Policy Information on the CMS website.

    Late Enrollment Penalty

    Medicare beneficiaries may incur a late enrollment penalty (LEP) if there is a continuous period of 63 days or more at any time after the end of the individual’s Part D initial enrollment period during which the individual was eligible to enroll, but was not enrolled in a Medicare Part D plan and was not covered under any creditable prescription drug coverage. View the Creditable Coverage and Late Enrollment Penalty page on the CMS website.