Frequently Asked Questions About Prescription Drug Coverage

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.

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.

Blue Cross & Blue Shield of Rhode Island has partnered with OutcomesMTM to administer our Medication Therapy Management (MTM) program. The goal of our MTM program is to ensure 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 that 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.

To be eligible for the MTM program, you must meet all of the three criteria below.

  1. Have three or more chronic diseases including:
    • Acid/Reflux/Ulcers
    • Acute Coronary Syndrome
    • Alzheimer’s Disease
    • Anemia
    • Angina
    • Anticoagulation
    • Anxiety
    • Atrial Fibrillation
    • Autoimmune Disorders
    • Benign Prostatic Hyperplasia (BPH)
    • Bone Disease– Arthritis–Osteoporosis
    • Bone Disease– Arthritis–Rheumatoid Arthritis
    • Cancer
    • Cerebrovascular disease
    • Chronic Alcohol and Other Drug Dependence
    • Chronic Heart Failure
    • Chronic Non Cancer Pain
    • Coronary Artery Disease
    • Diabetes
    • Dyslipidemia
    • Edema
    • End stage liver disease
    • Glaucoma
    • Hepatitis C
    • HIV/AIDs
    • Hypertension
    • Mental Health–Bipolar Disorder
    • Mental Health–Chronic/Disabling Mental Health Conditions
    • Mental Health–Depression
    • Mental Health–Schizophrenia
    • Multiple Sclerosis
    • Neurologic Disorders
    • Parkinson’s Disease
    • Respiratory Disease–Asthma
    • Respiratory Disease–Chronic Lung Disorders
    • Respiratory Disease–Chronic Obstructive Pulmonary Disease (COPD)
    • Severe Hematologic Disordered
    • Stroke
  2. Be taking eight or more Part D covered drugs , and
  3. Have incurred one-fourth of the specified annual cost threshold ($3,967) in previous three months.

Blue Cross & Blue Shield of Rhode Island’s members who meet the criteria for participation will be sent an introduction letter that describes the MTM program. Specially trained pharmacists work closely with you and your doctors to solve any problems related to medicines and to help you get the best results.

As part of the program you will receive a Comprehensive Medication Review (CMR), which is an interactive person to person consultation with a pharmacist. CMR’s 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.

Medicare requires that MTM programs automatically enroll those who qualify through the calendar year, but participation is voluntary, and members are given the opportunity to opt out at any time. Please note that the MTM program is not considered a benefit and based on the limited eligibility criteria, not all plan members will qualify. This is a free service for eligible members.

You can take this personal medication list to your next doctor's appointment and complete it together with your doctor.

If you would like additional information or you do not wish to take part in the MTM program, please call the Medicare Concierge Team at the numbers on the Contact Us page.

Blue Cross & Blue Shield of Rhode Island is an HMO plan with a Medicare contract. Enrollment in Blue Cross & Blue Shield of Rhode Island depends on contract renewal.

Last updated: 01/01/2018

H4152_2018web5 Approved