• Pharmacy Services

  • About Out of Network Pharmacies

    In certain situations, prescriptions filled at an out-of-network pharmacy may be covered. Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available.

    Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

    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. If you do go to an out-of-network pharmacy for the reasons listed below, you may 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. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay for a covered Part D drug will help you qualify for catastrophic coverage. To learn how to submit a paper claim, please refer to the paper claims process described in the subsection below called “How do you submit a paper claim?”

    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.

    Coverage and Limitations for Out of Network Pharmacies

    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. 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 lose 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 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 (e.g. 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
    • 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.

    Premera Blue Cross can choose not to renew its contract with a partner pharmacy and any pharmacy may also refuse to renew the contract resulting in a termination or non-renewal. This may result in termination of the beneficiary’s in-network coverage at the non-renewing pharmacy. If this happens, you have a transition period to find another in-network pharmacy.

    The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, provider network, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year.

    Pharmacy Information

    2014 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.

    Formulary list of approved drugs 

    Premera Blue Cross Medicare Advantage Plans uses a List of Covered Drugs - The Drug List tells which Part D prescription drugs are 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 Premera Blue Cross Medicare Advantage Customer Service at 1-888-850-8526 (TTY: 711) seven days a week, 8 a.m. to 8 p.m. Pacific Time.)

    List of network pharmacies 

    Premera Blue Cross Medicare Advantage Provider and Pharmacy Directory 

    We have 642 pharmacies available in our service area in addition to 26,000 pharmacies nationwide. Premera Blue Cross Medicare Advantage Plans has contracts with pharmacies that equal or exceed the Centers for Medicare and Medicaid (CMS) requirements for pharmacy access in your area.

    Pharmacy Guidelines

    Read our question and answer segment on common Medicare pharmacy topics.

    Part D Coverage Determinations, Exceptions, Appeals and Grievances 

    Read more about Part D coverage determinations, exceptions, appeals and grievances

    Other important information: 

    If you qualify for Extra Help through Medicare your prescription drug premiums and costs may be reduced. 

    For more information, see the LIS Premium Summary Table or call:

    • 800-MEDICARE (800-633-4227). TTY users should call 877-486-2048, 24 hours a day/7 days a week;
    • The Social Security Office at 800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday.
    • TTY users should call, 800-325-0778; or your State Medicaid Office.

    Pharmacy Transition Process

    Premera Medicare Advantage Plans wants to make your prescription transition as safe and as easy as possible. Here is some information that will help guide you through any prescription drug transition(s). Please read about our transition policy for more information.

    Current Members

    If you are a current member of Premera Medicare Advantage Plans you may be affected by changes in our formulary from one year to the next. You may notice that the drug you are currently taking is no longer on the plan’s Drug List (formulary) or the drug you are taking is now restricted in some way. If your drug is not on our Drug List or is restricted in some way and you need help switching to a different drug that we cover or requesting a formulary exception please contact your Customer Service team at 888-850-8526.

    New Member Transition

    As a new member to our plan, you may be taking a drug that is not on our Drug List (formulary) or has certain restrictions, such as prior authorization, step therapy or quantity limits. While you talk to your doctor to determine the right course of action for you, we will cover a temporary 90-day supply or up to three 30-day supplies (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 90-day supply of drugs that are not on our Drug List or drugs that are restricted in some way we will require medical necessity review even if you have been a member of the plan less than 90-days.

    For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that is on our formulary or request a formulary exception so that we will cover the drug you take.

    New Member Transition as a Long-Term Care Resident

    If you are a resident of a long-term care facility, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90-days you are a member of our plan. If you need a drug that is not on our Drug List or is subject to other restrictions, such as step therapy, but you are past the first 90-days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless the prescription is for fewer days) while you pursue a formulary exception.

    New Member Transition Restrictions

    The Centers for Medicare and Medicaid Services (CMS) restricts coverage of some drug categories. Premera Medicare Advantage Plans will not cover these drugs during your transition. The following are examples of commonly excluded categories not covered under Medicare Part D:

    • Non-prescription drugs (also called over-the counter)
    • Drugs when used to promote fertility
    • Drugs when used for the relief of cough and cold symptoms
    • Drugs when used for cosmetic purposes or to promote hair growth
    • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
    • Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject
    • Drugs when used for the treatment of anorexia, weight loss, or weight gain
    • Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale
    • Barbiturates, except when used to treat epilepsy, cancer, or a chronic mental health disorder

    Medication Therapy Management (MTM) Program

    Premera Blue Cross Medicare Advantage Plan’s Medication Therapy Management (or “MTM” for short) Program helps make sure that 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. The pharmacist screens your medications for unnecessary or duplicate drugs, adverse drug reactions, doses that are too high, doses that are too low, opportunities for more effective medications, and opportunities to improve medication use. The pharmacist also reviews your Medicare Part D benefit to make sure you are getting the most from your coverage. Suggestions are made for you to achieve the most benefit from your medications. Recommendations regarding your medications may be sent to your doctor to help communicate questions and concerns.

    It is estimated that 1.5 million preventable adverse drug events occur in the United States each year. Pharmacist-provided MTM services can help to prevent these events and are associated with improved medication use, lower drug costs, improved disease management, reduced hospitalizations and reduced hospital readmissions.

    This program is voluntary and free for members who qualify.

    How do I qualify?

    The Medicare population of members with Premera Blue Cross Medicare Advantage Plans is reviewed each year to identify those who may be at the highest risk for adverse drug events. We look for people who:

    • Take (7 or more) multiple (part D) medications
    • Have a yearly drug spend that may be difficult to afford (greater than about $3000)
    • Have (3 or more) chronic illnesses including, but not limited to:
      • Osteoporosis
      • Rheumatoid arthritis
      • Heart Failure
      • Diabetes
      • Hyperlipidemia
      • Hypertension
      • Asthma
      • COPD

    How will I be notified?

    If you qualify, we will automatically enroll you in the program and mail information to you. A Premera Blue Cross Medicare Advantage Plan MTM pharmacy technician or scheduler will then call you to schedule a telephone appointment with the pharmacist. You may also request MTM materials and information by calling the phone number listed at the bottom of this page. If you decide not to participate, please notify us and we will withdraw you from the program.

    How does this benefit me?

    As part of the MTM program, each qualifying member will receive an offer of a telephone consultation with the pharmacist. The telephone consultation appointment usually takes 25 to 40 minutes. This consultation consists of a comprehensive medication review (“CMR”) of all your medications.

    The pharmacist will talk with you about any questions you may have like:

    • What is this medication for?
    • Must I take this medication?
    • Am I getting the most out of this medication?
    • Am I using this medication safely?
    • Are these herbal medications okay to take?
    • Is this medication causing a side effect?
    • Is there a more affordable option?
    • Am I getting the most out of my Medicare part D benefit?

    Following the telephone appointment you will receive a written summary of this discussion. The summary has a medication action plan that recommends what you can do to make the best use of your medications, with space for you to take notes or write down any follow-up questions. You will also get a personal medication list that will include all the medications you’re taking and why you take them. To obtain a Personal Medication List form, please contact Customer Service at 1-888-850-8526 (TTY: 711), 8 a.m. to 8 p.m. (Pacific Time), seven days a week.

    Targeted medication reviews (“TMRs”) are also conducted throughout the year. These TMRs address specific or potential medication-related problems and are used to assess medication use and monitor whether any unresolved issues need attention. TMRs may or may not require an additional 10-15 minute telephone conversation during the year.

    What do I do? I qualify, and I would like to participate.

    1. Schedule your pharmacist consultation telephone appointment
    2. Have your medication list and/or current medications available for your telephone appointment
    3. Have your over-the-counter medications, herbals, and supplements available for your telephone appointment
    4. Prepare a list of questions or concerns you may want to discuss with the pharmacist
    5. Be available at the agreed upon telephone number at the scheduled appointment date and time.

    Helpful Tip:

    Schedule your convenient Medication Therapy Management (“MTM”) telephone appointment three to four weeks before your annual wellness exam with your physician.

    The MTM Pharmacist can help you organize your concerns and questions. This can help you make the most of your appointment time with your physician.

    For questions regarding this program, contact Customer Service at 1-888-850-8526, seven days a week between 8 a.m. and 8 p.m. (Pacific Time). If you are hearing impaired and use a Teletype (TTY) Device, call our TTY line at 711.

    To obtain a Personal Medication List form, please contact Customer Service at 1-888-850-8526 (TTY: 711), 8 a.m. to 8 p.m. (Pacific Time), seven days a week.

    Frequently Asked Questions (FAQs)

    What is a Formulary?
    Can the Formulary change?
    How will I find out if my drug coverage has been changed?
    How do I Find an In-Network Pharmacy in My Area?
    How do I Fill Prescriptions Outside of the Network?
    What is Medication Therapy Management (MTM) Program?
    How does this benefit me?

    What is a Formulary? 

    Premera Blue Cross Medicare Advantage Plans uses a List of Covered Drugs (formulary or “Drug List”). The Drug List tells which Part D prescription drugs are 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. You may also review the most current version.

    Premera Blue Cross Medicare Advantage Plans covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and equally effective as brand-name drugs. When a generic drug is available for a brand name drug, the brand name drug will generally not be covered and is considered non formulary.

    Some drugs may have additional requirements or limits on coverage. These requirements and limits may include:

    • Prior Authorization:
      For certain drugs, you or your provider need to get approval from Premera Blue Cross Medicare Advantage Plans before we agree to cover the drug for you. This is called “prior authorization.” This means that your provider will need to contact us before you fill your prescription. If you don't get approval, Premera Medicare Advantage Plans may not cover the drug.
    • Quantity Limits:
      For certain drugs, Premera Blue Cross Medicare Advantage Plans limits the amount of the drug that you can have per prescription or for a defined period of time. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.
    • Step Therapy:
      In some cases, Premera Blue Cross Medicare Advantage Plans requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, then we will cover Drug B. This requirement encourages you to try safer or more effective drugs before the plan covers another drug.

    You can access the Premera Blue Cross Medicare Advantage Plans formulary online (PDF) or if you have questions regarding our formulary or our transition process you may contact the Premera Blue Cross Medicare Plans Customer Service Team at 888-850-8526. If you are hearing impaired and use a Teletype (TTY) Device, please call our TTY line at 711. Customer service is available between 8 a.m. and 8 p.m., seven days a week (Pacific Time).

    Can the Formulary change? 

    Yes, Premera Blue Cross Medicare Advantage Plans may make certain changes to our formulary during the year. Most changes in the formulary happen at the beginning of each year (January 1). However, during the year there may also be changes. For example, the plan might:

    • Add or remove drugs from the Drug List. New drugs, including new generic drugs may become available or there is a new use for an existing drug. We may remove a drug because it has been found to be ineffective or there may be a drug recall
    • Move a drug to a higher or lower cost-sharing tier 
    • Add or remove restrictions on coverage for a drug. (for more information about restrictions on drug coverage, refer to your Evidence of Coverage)
    • Replace a brand-name drug with a generic drug 

    In most cases Premera Blue Cross Medicare Advantage Plans must get approval from Medicare for changes that we make to the plan's Drug List. To get updated information about the drugs covered by Premera Blue Cross Medicare Advantage Plans, please call Customer Service at 888-850-8526, seven days a week, from 8a.m. to 8 p.m (Pacific Time). TTY/TDD users should call 711.

    How will I find out if my drug coverage has been changed? 

    If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we will send you a notice. Normally, we will let you know at least 60 days in advance. If a drug is suddenly recalled because it has been found to be unsafe we will remove the drug from the Drug List immediately. We will notify members taking the drug about the change as soon as possible.

    How do I Find an In-Network Pharmacy in My Area? 

    Premera Blue Cross Medicare Advantage Plans has approximately 642 participating pharmacies available for your use nationwide. You may look in your Provider Directory, visit our website (link to provider directory), or call Customer Service, whichever is easiest for you. You may also contact Customer Service to request a revised list of in-network pharmacies by 888-850-8526, seven days a week from 8 a.m. to 8 p.m. (Pacific Time). (TTY/TDD Users should call 711.) Note: Premera Blue Cross Medicare Advantage Plans has contracts with pharmacies that equal or exceed the Centers for Medicare and Medicaid (CMS) requirements for pharmacy access in your area.

    How do I Fill Prescriptions Outside of the Network? 

    Premera Blue Cross Medicare Advantage Plans has approximately 26,000 participating pharmacies available for your use nationwide. Generally, we only cover drugs filled at an out-of-network pharmacy when a network pharmacy is not available. 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. Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

    • 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 exists: You are traveling outside the service area and run out or lose your covered drugs or become ill and need a covered 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 (e.g. orphan or specialty drug with limited distribution)
    • The network mail-order pharmacy is unable to get the covered drug to you in a timely manner and you run out of your drug
    • 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 settings

    If you do go to an out-of-network pharmacy for the reasons listed above, you may have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost. Send us your request for payment along with your documentation of any payment you have made. You may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy's price is higher than what a network pharmacy would have charged. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy as any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage.

    What is the Medication Therapy Management (MTM) Program 

    Premera Blue Cross Medicare Advantage Plan’s Medication Therapy Management program helps make sure that your medications are working to improve your health. Pharmacists review your medication list and history. Learn more.

    How Does This Benefit Me? 

    As part of the program, each eligible member will receive an offer of a telephone consultation with the pharmacist. After completion of the consultation the member will receive a written summary including a current medication list. For questions regarding this program, contact Customer Service at 888-850-8526. If you are hearing impaired and use a Teletype (TTY) Device, call our TTY line at 711.

  • Contact Us

    Sales

    888-868-7767
    8 am to 8 pm Pacific Time
    7 Days a week

    TTY/TDD 711

    More contact info 

    Customer Service

    888-850-8526
    8 am to 8 pm Pacific Time
    7 Days a week

    TTY/TDD 711