Medicare services and coverage details

Blue Cross NC offers three drug formularies (drug lists) so Medicare beneficiaries can have options for their prescription needs.

Blue Medicare HMO Enhanced, HMO Essential, and Blue Medicare PPO Enhanced share the same Medicare prescription drug list. This list is based on a preferred list of FDA-approved prescription drugs and was developed using guidelines from the federal government. The drug list includes many highly utilized generic drugs and some brand name and specialty drugs. This list also includes a lower cost tier for some maintenance medications related to High Blood Pressure, High Cholesterol, and Diabetic conditions.

Blue Medicare Rx (PDP) Standard Plan prescription drug list is also based on a preferred list of FDA-approved prescription drugs and was developed using guidelines from the federal government. The drug list for this plan has many highly utilized generic drugs and some brand name and specialty drugs. Many of the most popular generic prescriptions are included.

The Blue Medicare Rx (PDP) Enhanced prescription drug list is based on a preferred list of FDA-approved prescription drugs and was developed using guidelines from the federal government. The drug list includes more generic, brand name and specialty drugs.

Generic drugs have the same active ingredient formulas as brand name drugs. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. Certain vaccinations, insulin and insulin injection supplies are also covered on all formularies. Over-the-counter drugs are not covered because they are excluded by Medicare.

To encourage the appropriate use of prescription drugs, some quantities are limited and some drugs must be approved before they will be covered. For more information, see prior authorization, step therapy, and quantity limitations.

Like most insurance coverage, our Blue Medicare HMO, Blue Medicare PPO, and Blue Medicare Rx plans have some limitations and exclusions.

The drugs listed below have been removed from the specified formularies (drug lists). Please ask your doctor to prescribe a drug that is on the formulary to treat your condition. Your drug cost will depend on your specific prescription drug plan and the formulary alternative prescribed by your doctor. If you are affected by a change to the formulary, you will receive a written notice regarding the change at least 60 days before the change will take effect.

Blue Medicare Rx Standard

These drugs have been withdrawn or discontinued by the manufacturer:

• Astramorph
• Azathioprine injection
• Elspar
• Freamine III 8.5%
• Leukine 500 mcg

The drug manufacturers have discontinued participation in the Coverage Gap Discount Program for these drugs:

• Krystexxa inj 8 mg/ml
• Oxandrin 2.5 mg and 10 mg

Blue Medicare HMO/PPO and Blue Medicare Rx Enhanced

These drugs have been withdrawn or discontinued by the manufacturer:

• Allopurinol injection
• Astramorph
• Azathioprine injection
• Celestone solution 0.6 mg/5 ml
• Cimetidine injection
• Elspar
• Freamine III 8.5%
• Leukine 500 mcg
• Onsolis
• Tobramycin injection 1.2 mg/ml in saline
• Tyzine 0.1%

The drug manufacturers have discontinued participation in the Coverage Gap Discount Program for these drugs:

• Krystexxa inj 8 mg/ml
• Oxandrin 2.5 mg and 10 mg

If you can't find your drug, your drug may not be covered. To verify whether a drug is covered, you may call Customer Service seven days a week from 8 AM to 8 PM.

• Blue Medicare Rx 888-247-4142; TTY 888-247-4145
• Blue Medicare HMO 888-310-4110; TTY 888-451-9957
• Blue Medicare PPO 877-494-7647; TTY 888-451-9957

If your drug is not covered, you have the right as a member to request that an exception be made to the formulary or to request a transition supply while you find an appropriate alternative prescription. For instructions on how to request a transition supply or an exception to the formulary and instructions on how to appeal a decision about an exception or to file a grievance if you are dissatisfied for any reason, please review our policies for Medicare members.