Drugs

  • What if my drug is not covered?

    If your drug is not included in the formulary, call customer service at 888-850-8526 (TTY/TDD: 711) Monday to Friday, 8 a.m. to 8 p.m., (or 7 days a week, 8 a.m. to 8 p.m., October 1 to March 31), and ask if your drug is covered.

    If you learn that Premera Blue Cross Medicare Advantage plans do not cover your drug, you can:

    • 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:

    • Ask us to cover a drug even if it's not on our covered drug list.
    • Ask us to cover a drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug.
    • Ask us to waive coverage restrictions or limits on the 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.

    Formulary changes

    Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year, with these exceptions:

    • When a new, less expensive generic drug becomes available.
    • When new information about the safety or effectiveness of a drug is released.
    • The drug is removed from the market.

    Changes to the drug list that will affect members currently taking a drug:

    • New generic drugs: We may immediately remove a brand-name drug on our formulary if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand-name drug on our formulary, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand-name drug, we may not tell you before we make that change, but we will later provide you with information about the specific change(s) we have made. If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you.
    • Drugs removed from the market: If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
    • Other changes: We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective.

    Information on formulary changes can be found on the Medicare Forms page.

    Transition (temporary supply)

    As a new or continuing member, you may be taking drugs that are not on our formulary (which is the list of drugs covered on your plan), or you may be taking a drug that is on our formulary, but your ability to get it is limited. For example, you may need prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an alternative drug that we cover or request a formulary exception. If a formulary exception request is approved, we will cover the drug you take, even though it is not on the formulary.

    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 a member of our plan. This is called a transition supply of drugs. Here’s how a transition supply is provided to you for each of your drugs not on our formulary or for your covered drugs that are available only with limits, such as prior authorization:

    • New members: We will cover a temporary one-month supply within the first 90 days you are a member of the plan.
    • Current members who are experiencing a negative formulary change year over year: We cover a temporary one-month supply during the first 90 days of the new plan year.
    • If your prescription is written for fewer days, we will allow refills to provide up to a maximum one-month supply of medication. After your first one-month supply, we will not pay for these drugs, even if you have been a member of the plan fewer than 90 days.
    • If you live in a long-term care facility, we’ll provide an emergency supply of any drug you need that’s not on our formulary or any drug that’s covered but with limits. If you’re past the first 90 days of membership in our plan, we’ll cover a 31-day emergency supply of that drug while you pursue a formulary exception.

    2019 Medicare Advantage Drug Transition Policy

    Long-term and monthly supply

    You can fill a long-term supply of some medications using our mail-order pharmacy or at many of the retail pharmacies in our network. What qualifies as a monthly supply and a long-term supply for each of our plans:

    Premera Blue Cross Medicare Advantage (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO), and Core (HMO):

    • Monthly supply is a maximum of a 30-day supply
    • Long-term supply is a 90-day supply

    Premera Blue Cross Medicare Advantage Sound + Rx (HMO), Peak + Rx (HMO), Charter + Rx (HMO):

    • Monthly supply is a maximum of a 31-day supply
    • Long-term supply is a 93-day supply