Frequently Asked Questions About Prescription Drug Coverage

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If you paid out-of-pocket for a covered prescription drug, please complete the Prescription Reimbursement Claim Form (coming soon) 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.
 

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). In these situations, please check first with Customer Service to see if there is a network pharmacy nearby.

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 (coming soon) for reimbursement.

The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs to Part D enrollees who have reached the coverage gap and are not already receiving “Extra Help.” A 50% discount on the negotiated price (excluding the dispensing fee and vaccine administration fee, if any) is available for those brand name drugs from manufacturers that have agreed to pay the discount. The plan pays an additional 2.5% and you pay the remaining 47.5% for your brand drugs.

If you reach the coverage gap, we will automatically apply the discount when your pharmacy bills you for your prescription and your Explanation of Benefits (EOB) will show any discount provided. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and moves you through the coverage gap. You also receive some coverage for generic drugs. If you reach the coverage gap, the plan pays 28% of the price for generic drugs and you pay the remaining 72% of the price. The coverage for generic drugs works differently than the coverage for brand name drugs. For generic drugs, the amount paid by the plan (28%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap. Also, the dispensing fee is included as part of the cost of the drug.

If you have any questions about the availability of discounts for the drugs you are taking or about the Medicare Coverage Gap Discount Program in general, please contact Customer Service.

BlueCHiP for Medicare Preferred, BlueCHiP for Medicare Group Preferred and BlueCHiP for Medicare Group Preferred Unlimited Plan Members: Because your plan offers additional gap coverage during the Coverage Gap Stage, your out-of-pocket costs will sometimes be lower than the costs described here. Please refer to Chapter 6 of your Evidence of Coverage for more information about your coverage during the Coverage Gap Stage.

Formulary Changes
Generally, if you are taking a drug on our 2014 for­mulary that was covered at the beginning of the. year, we will not discontinue or reduce coverage of the drug during the 2014 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

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 60 days before the change becomes ef­fective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-­day supply of the drug. 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.

Our plan provides coverage of a number of Part D vaccines. There are two parts to our coverage of Part D vaccinations:

  • The first part of coverage is the cost of the vaccine medication itself. The vaccine is a prescription medication.
  • The second part of coverage is for the cost of giving you the vaccination shot. (This is sometimes called the “administration” of the vaccine.)
 
What do you pay for a Part D vaccination?

1. The type of vaccine (what you are being vaccinated for). 

  • Some vaccines are considered medical benefits. Please refer to Chapter 4 of your Evidence of Coverage to find out about your coverage of these vaccines.
  • Other vaccines are considered Part D drugs. You can find these vaccines listed in the plan’s List of Covered Drugs (Formulary). 

2. Where you get the vaccine medication. 

3. Who gives you the vaccination shot. 

What you pay at the time you get the Part D vaccination can vary depending on the circumstances. For example: 
  • Sometimes when you get your vaccination shot, you will have to pay the entire cost for both the vaccine medication and for getting the vaccination shot. You can ask our plan to pay you back for our share of the cost. 
  • Other times, when you get the vaccine medication or the vaccination shot, you will pay only your share of the cost. 
 
Remember you are responsible for all of the costs associated with vaccines (including their administration) during the Coverage Gap Stage of your benefit. (BlueCHiP for Medicare Preferred, BlueCHiP for Medicare Group Preferred and BlueCHiP for Medicare Group Preferred Unlimited Plan members: depending on which tier the vaccine is on, you may have coverage for some vaccines during the gap). 
 
Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccination shot at the network pharmacy. (Whether you have this choice depends on where you live. Some states do not allow pharmacies to administer a vaccination.) 
  • You will have to pay the pharmacy the amount of your coinsurance or copayment for the vaccine itself.
  • Our plan will pay for the cost of giving you the vaccination shot. 
 
Situation 2: You get the Part D vaccination at your doctor’s office. 
  • When you get the vaccination, you will pay for the entire cost of the vaccine and its administration. 
  • You will be reimbursed the amount you paid less your normal coinsurance or copayment for the vaccine (including administration). 
 
Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor’s office where they give you the vaccination shot. 
  • You will have to pay the pharmacy the amount of your coinsurance or copayment for the vaccine itself. 
  • When your doctor gives you the vaccination shot, you will pay the entire cost for this service.
  • You will be reimbursed the amount charged by the doctor for administering the vaccine. 
 
Please note: Some vaccines are considered medical benefits. You can find out about your coverage of these vaccines by going to Chapter 4, Medical Benefits Chart (what is covered and what you pay) in your Evidence of Coverage.The rules for coverage of vaccinations are complicated. We are here to help. We recommend that you call us first whenever you are planning to get a vaccination. We can tell you about how your vaccination is covered by our plan and explain your share of the cost.
  • We can tell you how to keep your own cost down by using providers and pharmacies in our network.
  • If you are not able to use a network provider and pharmacy, we can tell you what you need to do to get payment from us for our share of the cost.