Drug Coverage

The Blue Cross Community MMAI plan includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. This list includes generic and brand drugs and medical supplies. It also includes the drugs covered by Medicare Part D.

View the Drug List

As a member, you pay nothing ($0) for the items on the Drug List. Those items will be covered as long as you:

  • Have a medical need for them
  • Have a prescription from your doctor for them
  • Fill the prescription at a network pharmacy
  • Follow the plan rules

Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. However, you can order these items once every three months. The plan will pay up to $30 (plus $5 for shipping) for each order. See the Member Handbook Link to Member Handbook PDF for more details.

Certain drugs on the list need prior authorization. Your doctor will need to request approval before these drugs can be prescribed. Without approval, the drug won't be covered. Your doctor will choose which drug is best for you. If your doctor wants you to have a drug that is not on the list, he or she can request approval for that drug. For some drugs, the plan limits the amount that will be covered. You can find out if your drug has any added conditions or limits by looking at the Drug List.

To protect your health and keep you safe, make sure your doctor and pharmacist know what medicines you are taking, including OTC drugs.


Pharmacies

Our network has many pharmacies for you to use. These pharmacies meet or exceed the Centers for Medicare & Medicaid Services (CMS) requirements for pharmacy access in your area.

View the Pharmacy Directory Link to Provider Pharmacy Directory PDF.


Drug Plan Transition

If you are new to our plan or affected by a level of care change you may be taking medications that are NOT included on the plan's drug list. In this case, you may be eligible for a temporary supply of that medication during your transition. You'll qualify if you:

  • Are new to our plan
  • Switch from another plan to our plan
  • Are affected by a level of care change (for example, admitted or discharged from a long-term care facility)
  • Are affected by formulary changes from one year to the next

This transition coverage may continue your current medication, allowing time for your doctor to:

  • Change your prescription to an alternate medication that's included on the plan's formulary
  • Send an exception request so your medication will continue to be covered based on medical necessity

View more details about our transition policy:


Mail-Order Service

If you take certain medicines on a regular basis, you can order the drugs that you take long-term or every day from home and have them delivered. With our mail-service pharmacy program, you can get up to a 90-day supply at one time.

To learn more about the plan's drug coverage, see the Member Handbook Link to Member Handbook PDF


Medication Therapy Management

What is Medication Therapy Management?

The Medication Therapy Management (MTM) program reviews the medicines you take to make sure that they're safe, work well and fit your lifestyle. This program is offered at no additional cost to eligible members.

The goal is to help you get the best results from your medicines, at the lowest possible price. MTM can help you:

  • Learn how to get the most from your medicines
  • Lower your risk for potential harmful drug reactions and side effects
  • Learn why it's important to take your medicines on time

MTM can help you and your doctor make sure that your medicines are the best choice for you.

Who's eligible for MTM?

You're automatically enrolled in the MTM program if you:

2016

2017

1. Have three or more of the following conditions:

  • Asthma
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Depression
  • Diabetes
  • Heart failure
  • High blood pressure
  • High cholesterol
  • Osteoarthritis
  • Osteoporosis

1. Have three or more of the following conditions:

  • Chronic Heart Failure
  • Diabetes
  • High blood pressure
  • High blood cholesterol
  • Rheumatoid arthritis

AND

AND

2. Take six or more covered Medicare Part D prescriptions.

2. Take eight or more prescription medicines covered by Medicare Part D.

AND

AND

3. Expect to spend more than $3,507 in 2016 on covered Medicare Part D prescriptions.

3. Expected to spend more than $3,919 in 2017 on prescription medicines covered by Medicare Part D.

What you can expect

MTM is a two-part program. Reviews can be done over the phone, whenever it's convenient for you. In some cases, you may have an in-person review.

1. Comprehensive medication review

This personalized review lets you talk one-on-one with a pharmacist.

To get ready for your review make a list of all the medicines you take. Include how much you take each day and how often you take them. Even over-the-counter medicines or supplements. The pharmacist will review your list and talk about it with you. This usually takes about 30 minutes.

After your review, you'll get a complete list of your medicines – a personal medication list Personal Medication List PDF – and an action plan that you can bring with you to your next doctor's visit.

2. Targeted medication review

Every few months, the program reviews your prescription claims to make sure there are no issues that need attention. A pharmacist will look for ways to improve your medicine therapy. If the review identifies any issues, he or she will contact you and your doctor.

Getting started

If you're eligible for MTM, you're automatically enrolled. You'll get a letter or phone call letting you know how to schedule an appointment or opt out of the program.

Opting out

Medicare requires us to automatically enroll you if you're eligible. But, this service is voluntary – you're not required to participate. You can cancel your enrollment at any time during the calendar year. Your prescription drug coverage will not change if you take part in the MTM program or not.

For more information

If you'd like to know more, call the member service phone number on the back of your member ID card. Ask to speak to someone about the MTM program.


Medicare Part D and Medicaid Drugs

When you join our plan, if you are taking any prescription or over-the-counter drugs that Blue Cross Community MMAI does not normally cover, you can get a temporary supply. We will help you get another drug or get an exception for Blue Cross Community MMAI to cover your drug, if medically necessary.

Coverage Determination

If your doctor or pharmacist tells you that we will not cover a prescription drug you should contact us and ask for a coverage determination.

If you request an exception, your doctor must provide a statement to support your request. You can learn more about when you may want to ask for a coverage determination in the Member Handbook External link to a PDF displaying the Member Handbook.

Download a Form:

For Medicare Drugs:

For Medicaid Drugs:

For assistance, contact Member Services at 1-877-723-7702 (TTY/TDD 711).

Appeal

If we do not accept your coverage determination, you may want to ask for an appeal. If you want to appeal, you must request it within 60 days after the date that your coverage determination is denied.

You, your doctor, or your representative may request an appeal. You can name a relative, friend, attorney, doctor or someone else to be your representative.

Download a Form:

You can also call Member Services at 1-877-723-7702 (TTY/TDD 711) to learn how to appoint a representative.

File a Grievance

A grievance is a complaint about any matter besides a service that has been denied, reduced or ended. It is different from a coverage determination because it usually does not involve coverage or payment for prescription drugs.

If you have a grievance, we encourage you to call Member Services at 1-877-723-7702 (TTY/TDD 711). You may also contact Medicare by using the online form at www.medicare.gov External Link to Medicare.gov.

Information on how to obtain aggregate number of grievances, appeals, and exceptions can be requested by phone, written mail requests or by fax.

Member Services: 1-877-723-7702 (TTY/TDD 711)

Mailing Address:
Blue Cross Community MMAI
Appeals and Grievances
P.O. Box 27838
Albuquerque, NM 87125-9705

Fax: 1-866-643-7069

General Information Questions

Additional information about your benefits can be requested by phone, written mail requests or by fax.

Member Services: 1-877-723-7702 (TTY/TDD 711)

Mailing Address:
Blue Cross Community MMAI
Medicare Part D General Information
P. O. Box 3836
Scranton, PA 18505

Fax: 1-855-674-9193


Prime Therapeutics, LLC, is the pharmacy benefit manager for Blue Cross and Blue Shield of Illinois.

 

Use our Provider Finder® to search for doctors and other health care providers near you.

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