Care Management

Care Management programs are available to BlueMedicare PFFS members. Providers both in and outside of Florida are encouraged to refer patients to these programs when appropriate.

We recognize that Medicare members have unique needs, and that's why we offer programs to help meet those needs. These include programs for disease management, case management and drug management.

Disease Management:
The Blueprint for Health^® Disease Management Education program provides members with information and support for chronic conditions such as diabetes, asthma and heart failure, and emphasizes the importance of talking to their doctor. A dedicated team of Registered Nurses (RN) is available to:

• Talk with members about their condition and help recognize early warning signs
• Help members understand their health care benefits
• Assist members in making informed health care decisions
• Provide information on how to access appropriate resources or health care providers

This program is offered at no additional cost to members.

Case Management:
The Blueprint for Health^® Case Management program focuses on serious or chronic illnesses. The member's nurse case manager works closely with members and their physician to assess their health care needs and to coordinate services, providing members with personalized solutions.

This program is voluntary and offered at no additional cost. For more information about Blueprint for Health, view the Blueprint for Health Medicare Advantage Brochure (PDF).

Drug Management:
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of physicians and/or pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members.

The requirements for coverage or limits on certain drugs are listed as follows:

• Prior Authorization: Certain drugs with special indications require authorization. These drugs are noted on the formulary. If they don't get approval, we may not cover the drug.
• Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time.
• Step Therapy: In some cases, we require a member to first try one drug to treat a medical condition before we will cover another drug for that condition.

BlueMedicare PFFS has a Medicare Advantage contract approved by the Centers for Medicare & Medicaid Services. Contracts are renewed annually and availability of coverage beyond the end of the current contract year is not guaranteed. A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. A doctor or hospital must agree to accept the plan's terms and conditions prior to providing health care services to a member, with the exception of emergencies. If a doctor or hospital does not agree to accept our payment terms and conditions, they may not provide health care services to the member, except in emergencies.