Pharmacy

• 2009 BlueMedicare Rx Comprehensive Formulary (PDF)
• BlueMedicare Rx Pharmacy Directory (PDF)
• Coverage Determinations – Here you will find information on how to request a decision for Medicare Part D drugs and guidance on how to express any other concerns.
• BlueMedicare Rx Forms

Drug Management Programs

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.