BlueRx PDP Conditions and Limitations Potential for Contract Termination Disenrollment Rights and Instructions Exceptions, Prior Authorization, Appeals and Grievances Out-of-Network Coverage Quality Assurance Policies and Procedures Link to Specific Guidance Regarding Exceptions and Appeals
BlueRx PDP: Conditions and Limitations Access Requirements BlueRx PDP has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. BlueRx PDP has a large national network of more than 58,000 pharmacies, including chain and independent drug stores. Network Limitations Enrollees must use network pharmacies or the BlueRx PDP mail order pharmacy service to receive covered Part D drugs except under emergency or non-routine circumstances. When obtaining prescriptions from pharmacies outside the network, the coverage by BlueRx PDP may be less. In the event that you use a pharmacy outside of BlueRx PDP s national pharmacy network, you may need to pay for the drug in full and submit a claim to BlueRx PDP for reimbursement. Eligible out-of-network claims will be paid at the rate the drug would have been paid for if you had purchased the drug from a BlueRx PDP network pharmacy. You will be responsible for the difference between the amount BlueRx PDP would have paid a network pharmacy and the price you paid, in addition to your applicable copayment or coinsurance. Formulary BlueRx PDP uses a formulary. A formulary is a list of covered drugs selected by BlueRx PDP in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The plan may periodically make changes to the formulary. If the formulary changes, affected enrollees will be notified in writing at least 60 days before the change is made, except in the case 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.. BlueRx PDP, as with all Medicare prescription drug plans, covers drugs that are listed on a formulary. BlueRx PDP covers all Part D drugs allowed by Medicare. You and your prescribing physician may ask for coverage of a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a tiering exception. This would lower the copayment amount you must pay for your drug. You cannot ask that a Part D drug on the specialty tier be covered at a higher level of payment.
Brand Drugs vs. Generic Drugs When a generic version of a brand name drug is available, our network pharmacies must provide you with the generic version. However, if your doctor has told us the medical reason that the generic drug will not work for you, then we will cover the brand name drug. Your share of the cost may be greater for the brand name drug. Days Supply Prescriptions for 1-34 days will require the same copayment as a 34-day supply and any prescriptions beyond 34 days (35-90 days) will be charged the same copayment as a 90- day supply. Prescriptions obtained at a retail pharmacy for 35-90 days may have a higher copayment than those received through the BlueRx PDP mail order pharmacy service. Eligibility Restrictions Anyone who is entitled to Medicare Part A benefits or enrolled in Medicare Part B is eligible to enroll in a Medicare-approved prescription drug plan. However, if you are enrolled in a Medicare Advantage plan such as an HMO or PPO and then enroll in a BlueRx PDP plan, you will be disenrolled from your Medicare Advantage plan. You will not be disenrolled if your plan is a Medical Savings Account plan or a private fee-forservice plan that does not provide Medicare-approved prescription drug coverage. You must also live in Pennsylvania or West Virginia to enroll in BlueRx PDP and not be enrolled in any other Medicare-approved prescription drug plan. Individuals with Medicare may enroll in a prescription drug plan during specific times of the year. You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, contact: 1-800-MEDICARE (1-800-633-4227) 24 hours a day, seven days a week. TTY/TDD users call 1-877-486-2048, www.medicare.gov on the Web. The Social Security Administration at 1-800-772-1213 (TTY/TDD users call 1-800-325-0778), between 7 a.m. and 7 p.m., Monday through Friday, www.socialsecurity.gov on the Web. Your state Medicaid office BlueRx PDP: Potential for Contract Termination All Medicare Prescription Drug Plan Sponsors agree to offer the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Prescription Drug Plan leaves the program, you will not lose Medicare coverage. If a sponsor decides not to continue, it must send you a letter at least 60 days before your coverage will end. The letter will explain your options for choosing another Medicare prescription drug coverage in your area.
BlueRx PDP: Disenrollment Rights and Instructions Voluntary Disenrollment During the Annual Election Period (November 15 through December 31), anyone with prescription drug coverage may disenroll from any Medicare Prescription Drug Plan and join another Medicare Prescription Drug Plan, or join a Medicare Advantage Plan with prescription drug coverage, or choose not to have any Medicare prescription drug coverage. Generally, you may not disenroll from BlueRx PDP and enroll in a new Medicare Prescription Drug Plan during other times of the year unless you qualify for a Special Election Period. If you wish to leave BlueRx PDP, and you are not enrolling in another Medicare Prescription Drug Plan, you will need to submit a written and signed disenrollment request to BlueRx PDP. You may also call 1-800-MEDICARE. Medicare Customer Service Representatives are available 24 hours a day, seven days a week. TTY/TDD users should call 1-877-486-2048. Until your disenrollment is effective, you must continue getting your eligible Part D drugs through BlueRx PDP. Involuntary Disenrollment BlueRx PDP may end your coverage for any of the following reasons: You are no longer eligible for Medicare prescription drug coverage BlueRx PDP is no longer contracting with Medicare or leaves your service area You permanently move out of the BlueRx PDP service area You materially misrepresent third-party reimbursement You fail to pay your BlueRx PDP premium You engaged in disruptive behavior, provided fraudulent information when you enrolled or knowingly permitted abuse or misuse of your enrollment card Please consult the BlueRx PDP Evidence of Coverage for complete information on disenrollment rights. BlueRx PDP: Coverage Decisions, Exceptions, Prior Authorizations Appeals and Grievances Coverage Decisions A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. With this decision, we explain whether we will provide the Part D drug you are requesting, or pay for the Part D drug you already received. If a drug is not covered in the way you would like it to be covered, you can ask the Plan to make an exception. An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. Click on the Link to Specific Guidance Regarding Exceptions and Appeals for information about how to request a Coverage Decision.
Exceptions Members of BlueRx PDP and their prescribing physicians may ask for coverage of a nonpreferred Part D drug at the preferred cost-sharing level. This is a request for at tiering exception. This would lower the copayment amount you must pay for your drug. You cannot ask that a Part D drug on the specialty tier be covered at a higher level of payment. A member s prescribing physician may either contact BlueRx PDP directly to request an exception or provide supporting information to BlueRx PDP if the request is made by the member. Generally, a request will be approved only if the alternative drugs included in the formulary would not be as effective in treating a condition and/or would result in adverse medical effects. Generally, the Plan must make a decision as expeditiously as the member s health requires, but no later than 72 hours of receiving supporting information from the member s physician for a standard request. If applying the standard timeframe (72 hours) for making the determination seriously jeopardizes the life or health of the member or the member s ability to regain maximum function, an expedited review can be requested. In this instance, the Plan must make a decision as expeditiously as the member s health requires, but no later than 24 hours of receiving supporting information from the member s physician. Prior Authorizations In addition to the exception process addressed above, BlueRx PDP requires you to get prior authorization for certain drugs. Even if a drug is on BlueRx PDP s formulary, it may still require prior authorization. This means that you will need to get approval from BlueRx PDP before you fill your prescription for a drug that requires prior authorization. If you don t obtain approval, BlueRx PDP may not cover the drug. Appeals and Grievances Members of BlueRx PDP, their physicians, or authorized representatives acting on the member s behalf may request an appeal of an adverse coverage determination made by BlueRx PDP. Examples of reasons an appeal may be filed include: the member believes he or she was denied benefits that the member is entitled to receive, the member believes there has been a delay in providing or approving the drug coverage, or the member disagrees with the amount of cost sharing he or she is required to pay. A request for a Standard Appeal can be made orally or in writing to BlueRx PDP. BlueRx PDP is required to notify the member in writing of its decision as quickly as the member's health condition requires, but no later than 7 calendar days from the date BlueRx PDP receives the request for the Standard Appeal. Members of BlueRx PDP and their prescribing physicians may request that an appeal be Expedited for situations in which applying the Standard Appeal process may seriously jeopardize the member's health, life or ability to regain maximum function. (This would not include requests for payment of drugs already furnished.) A request for an Expedited Appeal can be made orally or in writing. BlueRx PDP is required to notify the member and the prescribing physician of its decision as quickly as the member's health condition requires, but no later than 72 hours after receiving the request.
Members of BlueRx PDP may file a Grievance, either orally or in writing, expressing dissatisfaction with the operations, activities or behavior of BlueRx PDP or with the quality of care or service received from a BlueRx PDP provider. BlueRx PDP is required to respond to the member's Grievance as quickly as the case requires, but no later than 30 days after the date BlueRx PDP receives the oral or written Grievance. Please refer to the BlueRx PDP Evidence of Coverage for details on the Appeals and Grievance process. Obtaining Data on Exceptions, Appeals and Grievances Members of BlueRx PDP can receive a description of the number of Exceptions, Appeals and Grievances received and how these cases were resolved by contacting BlueRx PDP by phone or in writing. BlueRx PDP: Out-of-Network Coverage Obtaining Out-of-Network Coverage To get a complete description of your prescription drug coverage, including how to have your prescriptions filled, please review the Evidence of Coverage. A network pharmacy is a pharmacy that has agreed to provide prescription drug benefits at negotiated prices for BlueRx PDP. In most cases, your prescriptions are covered under BlueRx PDP only if they are filled at a network pharmacy or through our mail order pharmacy service. We will fill prescriptions at non-network pharmacies under certain circumstances. The following are a few exceptions when we will pay for a prescription filled at a pharmacy outside of our network. Getting coverage when you travel or are away from the plan s service area If you are traveling within the United States and territories and become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To learn how to submit a paper claim, please refer to the paper claims process described later. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency. What if I need a prescription because of a medical emergency or because I needed urgent care? We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgent care. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. If you go to an out-of-network pharmacy, you may be
responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To learn how to submit a paper claim, please refer to the paper claims process described later. Other times you can get your prescription covered if you go to an out-of network pharmacy We will cover your prescription at an out-of-network pharmacy if at least one of the following applies: If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24 hour service. If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (such as high-cost and unique drugs). If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and is administered in your doctor s office. If you are evacuated or displaced from your residence due to a State or Federally declared disaster or health emergency. Before you fill your prescription in any of these situations, call Member Service to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed above, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To learn how to submit a paper claim, please refer to the paper claims process described next. How do I submit a paper claim? When you go to a network pharmacy your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy because of the reasons listed above, the pharmacy may not be able to submit the claim directly to us and you will have to pay the full cost of your prescription. When you return home, simply submit your claim and your receipt to the following address: BlueRx PDP, PO Box 890388 Camp Hill, PA 17089. Upon receipt, we will make an initial coverage determination on the claim. Please refer to your Evidence of Coverage for more information on coverage determinations. For more information For more detailed information about your BlueRx PDP prescription drug coverage, please review the Evidence of Coverage and BlueRx PDP s formulary.
BlueRx PDP: Quality Assurance Policies and Procedures Medication Therapy Management (MTM) Program BlueRx PDP offers medication therapy management programs (MTM) at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these MTM programs to help up provide better coverage for our members. We offer an MTM program for members that have 3 of the following conditions bone disease, chronic heart failure, diabetes, dyslipidemia, hypertension. We may contact members who qualify for these programs. These programs are not a benefit to BlueRx PDP members. The programs are voluntary and you do not need to pay anything extra to participate. If you are selected to participate, we will send you information about the specific program, including information about how to access the program. For more information on BlueRx PDP MTM programs, please review the Evidence of Coverage or contact member service. Prior Authorization BlueRx PDP requires you to get prior authorization for certain drugs. This means that you will need to get approval from BlueRx PDP before you fill certain prescriptions. If you don t get approval, BlueRx PDP may not cover the drug. Our prior authorization policies are in place to ensure the safe and effective use of medications. Quantity Limits For safety purposes, certain drugs are covered in limited amounts per prescription. For example, BlueRx PDP provides up to 9 tablets per prescription for the drug Imitrex. Pharmacy Messaging Alert System BlueRx PDP has a real-time messaging alert system in place to inform pharmacists of potential drug problems. When a pharmacist, who is dispensing a drug, bills BlueRx PDP, the computer system performs a series of clinical checks. These will alert the pharmacist of potential drug to drug interactions, as well as higher or lower doses than are normally prescribed. These alerts serve to increase the quality and safety of pharmacy and patient interactions. Important Information about Plan Performance Ratings The Centers for Medicare and Medicaid Services (CMS) has made information available about our plan s performance ratings, including how it has been rated by plan members and how it compares to similar plans. This information is available for you to view at www.medicare.gov. Specific information about one of our plans may also be requested by calling the phone or TTY number in your enrollment information or on your identification card once you become a member.