Frequently asked questions about prescription drug coverage

How do I submit a claim for a prescription filled at a non-network pharmacy?

If you paid out-of-pocket for a covered prescription drug, please complete the Prescription Reimbursement Claim Form and mail it to the appropriate address listed on the form.

We will pay our share of the cost based on the drug payment stage you are in.

Find the Prescription Reimbursement Claim Form:

  1. Log in to your BCBSRI account and choose the “Go to myPrime.com” link.
  2. Use the "Forms" dropdown menu and select "Plan Documents."
  3. Select "Medicare Prescription Drug Claim Form"

When can I get a prescription filled at a non-network pharmacy?

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. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

  • The prescription is for a medical emergency or urgent care.
  • You are unable to get a covered drug in a time of need because there are no 24-hour network pharmacies within a reasonable driving distance.
  • The prescription is for a drug that is out of stock at an accessible network retail or mail service pharmacy (including high-cost and unique drugs).
  • You are limited to a 30-day (31-days for a long-term care) supply of drugs when filled at an out-of-network pharmacy.

If you fill a prescription at a non-network pharmacy, you will need to pay for the entire cost of the prescription and submit a prescription claim form for reimbursement.

Medication Therapy Management Program

Blue Cross & Blue Shield of Rhode Island offers a Medication Therapy Management (MTM) program with the goal of ensuring you are receiving the most effective medications, while also helping to reduce the risk of side effects and drug interactions as well as your out-of-pocket costs. The program is paid in full by your plan. This means you can receive the benefits of the MTM program at no cost to you. There is no change to insurance benefits, copays, prescription coverage, or available doctors or pharmacies.

As part of the program you will receive a Comprehensive Medication Review (CMR), which is an interactive, person-to-person consultation with a pharmacist. CMRs may occur face-to-face, over the phone, or using telehealth. During the review, a licensed pharmacist reviews your medications, vitamins, herbals, and supplements. The pharmacist will identify any duplicate medications, complications, and more cost-effective alternatives. The pharmacists will also complete your Personal Medication List with you and provide you with your medication action plan, which outlines what you have talked about and what you need to do (when to take medication, how, for what, etc.). You should share this plan with your doctor. The medication review takes about 30 minutes to complete. Targeted Medication Reviews are completed on a quarterly basis. As part of this review, prescription claims history is reviewed and any potential drug therapy concerns are identified and member interventions will occur as needed.

If you would like additional information or you do not wish to take part in the MTM program, please call the Medicare Concierge team.

For more details, please see our Medication Therapy Management page.