Drug formulary frequently asked questions

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How much will I pay for BCN Advantage-HMO covered drugs

BCN Advantage pays part of the costs for your covered drugs and you pay part. The amount you pay depends on the drug tier your drug is in under our plan and whether you fill your prescription at a preferred network pharmacy. (You can find out which drug tier your drug is in by looking in the formulary.)

Please refer to your Evidence of Coverage or call us to find out what your costs are. If you qualified for extra help with your drug costs, your payments for your drugs may be different.

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How do I use the formulary?

There are two ways to find your drug within the formulary:

Medical Condition — The drugs in the formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used for, look for the category name then look under the category name for your drug.

Alphabetical Listing — If you are not sure what category to look under, look for your drug in the index. The index provides an alphabetical list of all of the drugs included in the formulary. Both brand-name drugs and generic drugs are listed. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list.

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What about the drugs I currently take?

New BCN Advantage members may be taking drugs that are not in our formulary or that are subject to certain restrictions, such as prior authorization or step therapy.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 34-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 34-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long term care facility, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Members should ask their doctors to decide if they should switch to an appropriate drug that we cover or request a formulary exception (which is a type of coverage determination) in order to get coverage for the drug. See your Evidence of Coverage or call us to learn more about how to request an exception. While you talk to your doctor to determine the right course of action, we may cover the nonformulary drug in certain cases during the first 90 days of new membership.

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What if my drug is not on the formulary?

If your drug is not included in this formulary, call us and ask if your drug is covered.

Generally, we will only approve your request for an exception if there is a medical reason for it.

Call us to request an exception. Your physician will need to provide documentation regarding the reason for the requested drug. He or she will need to provide the reason why a formulary alternative won’t work for you, or information regarding the adverse effects that the available formulary agents caused when you tried them in the past.

You can also use the Member Request for Medicare Drug Coverage Determination Form (PDF) to request an exception to our coverage rules. Fax the completed form to 248-799-6393, or mail to:

BCN Advantage Mail Code C248
Blue Care Network
P.O. Box 5184
Southfield, MI 48076

If we deny your exception request, you can appeal our decision by phone or in writing. Please use the contact information above.

For more information, call Medicare at 800-MEDICARE (800-633-4227) 24 hours a day, 7 days a week (TTY 877-486-2048) or visit www.medicare.gov.

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How do I check the status of a drug exception request?

Call Customer Service. Contact information can be found on the Contact Us page.

Can the formulary change?

Yes. BCN Advantage Options 2 and 3 may add or remove drugs from the formulary. To find out which drugs are covered, please visit BCN Advantage formulary or call us.

If we remove drugs from our formulary; add prior authorization, quantity limits or step therapy restrictions; or move a drug to a higher cost-sharing tier, we must notify members who take the drug that it will be removed at least 60 days before the date that 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.

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What are generic drugs?

A generic drug has the same active ingredients as the equivalent brand-name drug. Generic drugs are approved by the Food and Drug Administration and usually cost less than brand name drugs.

We have programs to help ensure your medications are safe and  effective.

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Are there any other restrictions on coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Look in the formulary to see if your drug has any additional requirements or limits.

Exclusions

By law, certain types of drugs or categories of drugs are not covered by Medicare Drug Plans. For Options 2 and 3, these drugs or categories of drugs are called “exclusions” and include:

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Important information about this plan

BCN Advantage HMOSM is a health plan with a Medicare contract.

H5883_BCNAdvantageWebR4 CMS Approved 07012010

page modified 11/17/2009