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.


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

Medication Therapy Management (MTM) are programs for people who meet certain requirements for how much their total covered drug costs are, which medical conditions they have, and how many different drugs they take.

A team of pharmacists and doctors developed the MTM programs. They can help make sure you are using the drugs that work best to treat your medical conditions. The programs also help members avoid potential drug-related problems.

MTM programs are voluntary, free to MMAI members and are not considered a benefit. If we have a program that fits your needs, we will enroll you in the program and send you information. If you do not want to be in the program, please let us know, and we will take you out of the program.

Member Eligibility

You are automatically enrolled if you meet the following criteria:

  1. Have three or more of the conditions listed below:
    • Asthma
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Depression
    • Diabetes
    • Heart failure
    • High blood pressure
    • High cholesterol
    • Osteoarthritis
    • Osteoporosis
  2. Take six or more covered Part-D prescriptions, AND:
  3. Expected to spend more than $3,507 in 2016 on medication

Services offered:

  • Yearly Comprehensive Medication Review (CMR):

You will be asked to have all your medications with you. A trained MTM provider will review each of them, including how much and how often you take them. The review usually takes about 30 minutes. After the review, you will receive a summary of the discussion, Medication Action Plan, and a Personal Medication List (PML). A sample of the PML is included below.

  • Quarterly Targeted Medication Review (TMR)

Once every few months, your medications will be reviewed for certain medication issues. We may contact your health care provider if we find a potential problem.

These services are provided by telephone, or, in some cases, in person.

If you are enrolled in the MTM Program, you will get a welcome letter that tells you how to schedule a CMR.

For more information, or to receive MTM service documents, call the customer or member service phone number on the back of your member ID card. Ask to speak to someone about the MTM Program.

Personal Medication list PDF Document

If you have any questions about these programs, please contact Member Services or your Care Coordinator.

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).


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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