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Expenses For Prescription Drugs If there are medications you take on an on-going basis, you have the option of having your prescriptions delivered directly to you by mail under Standard Option. Here's how to obtain your prescription drugs, insulin, disposable syringes for covered injectable drugs, and diagnostic diabetic supplies with the convenient and economical Mail Service Program: Mail Service Program Standard Option Only: • First, ask your doctor to write you a prescription for up to a 90-day (or at least a 21-day) supply. If you are currently taking this medication, ask your doctor for a new written prescription. • Call Medco at 1.800.262.7890. A member services representative will send you the materials you will need to have your first mail service prescription sent to you and answer any questions you may have. • Put your prescription and your copayment (see the chart in the Medicare Part B Gaps chapter of this publication) in the ordering envelope and mail it to Medco. Please allow up to 14 days for delivery of your prescriptions, although you'll usually receive them sooner. • Your doctor's office can also order the prescription drugs you take on an ongoing basis with just a phone call. Simply show your Blue Cross and Blue Shield Service Benefit Plan ID card, and the physician can call toll-free at 1.888.327.9791 to get instructions for faxing your prescriptions. Your copayment will be billed to you later. You can order insulin, disposable syringes and covered diabetic supplies this way, too. And when it's time to refill your prescription, you can call it in toll-free, too. Just call 1.877.337.3455. You can also order your refills online using the Pharmacy Programs feature on this web site. Please allow one week for normal delivery. Specialist Pharmacists If you take a medication to treat a chronic condition, such as diabetes, acid reflux, or high cholesterol, you can receive expert, personalized care through one of the Medco Therapeutic Resource Centers. The Specialist Pharmacists who staff the Centers are trained in a single condition and the medications used to treat that condition. As a result, they are better equipped to answer any questions you may have about your treatment. If you would like to talk to a Specialist Phamacists about your condition, you can call member services at 1.800.262.7890 and ask to speak to a pharmacist. Retail Pharmacy Program Standard And Basic Option: The Retail Pharmacy Program provides savings on your out-of-pocket expenses for prescription drugs, insulin, disposable syringes for covered injectable drugs, and diabetic diagnostic supplies when you use a Preferred retail or Internet pharmacy. To use your Preferred network pharmacy benefits, you only need your Service Benefit Plan ID card. If you have Standard Option coverage and use out-of-network retail pharmacies, you need a Retail Prescription Drug Claim Form. Preferred Network Retail Pharmacies There are no claims to file when you use Preferred network pharmacies. Just show your Blue Cross and Blue Shield Service Benefit Plan ID card at Preferred network pharmacies when you have your prescription filled. Then, pay only your coinsurance amount under Standard Option and copayment or coinsurance amount under Basic Option for your medication or covered supply. If you have Standard Option and Medicare Part B as the primary payer, you are responsible for 25 percent of the PPA coinsurance when you use a Preferred network retail or Internet pharmacy. Under Basic Option, you pay a $10 copayment for generic drugs, a $30 copayment for formulary brand name drugs and 50 percent or $35 minimum for non-formulary Non-preferred brand name drugs for an initial 34 day supply. Benefits are not available for prescription drugs purchased at Non-preferred or out-of-network retail pharmacies. Remember, to get the Preferred price you must show your Service Benefit Plan ID card along with your prescription at the Preferred network pharmacy. If you don't show your card, you will be charged the full cost of the drug or supply, including the difference between the Preferred price and the full price. When you file a claim for your expenses, your benefits will not cover that difference in cost. You can call 1.800.624.5060 toll-free, 24 hours a day, to locate Preferred network pharmacies in any zip code area. When you call, be sure to have the zip code of the area in which you want to locate a pharmacy. If you wish to speak to a customer service representative, call from 8:00 a.m. to 9:00 p.m. weekdays and 8:00 a.m. to 6:00 p.m. on Saturday, except holidays (Eastern time). You can access our Preferred Internet pharmacies under the Pharmacy Programs feature on this web site. Preferred pharmacies are also listed in the Provider Directory. Preferred Network Long-Term Care Pharmacy Standard Option: Members who reside in nursing homes can receive Preferred network benefit levels for covered prescription drugs and supplies. The Preferred long-term care network is made up of pharmacies that serve nursing homes and nursing facilities. Call 1.800.624.5060 and speak to a customer service representative to find out if the pharmacy that serves the nursing home you're interested in is Preferred. Out-Of-Network Retail Pharmacies Basic Option: Benefits are not available for prescription drugs purchased at Non-preferred pharmacies. Standard Option: If you use a pharmacy that is not a Preferred network pharmacy, you must pay the full cost of your medication or supplies at the pharmacy. Then, fill out the special Retail Prescription Drug Claim Form and send it, along with your itemized bill, to: Service Benefit Plan You will be reimbursed for 55 percent of the Average Wholesale Price under Standard Option. Your benefits check should arrive within two weeks after the Retail Pharmacy Program receives your claim. Out-of-network pharmacies do not have to accept the AWP as payment in full. As a result, your out-of-pocket expenses are greater when you use these pharmacies. Prior Approval: Certain drugs and supplies require prior approval to determine whether they are eligible for benefits. All pharmacies, including Preferred network pharmacies, will ask you to pay the charge in full for drugs or supplies that need prior approval. Then, you can file the expense on a Retail Prescription Drug Claim Form to the Retail Pharmacy Program. Once approval has been given, future claims for the drug or supply will be filed directly by Preferred network pharmacies. Under Standard Option you can also use the Mail Service Prescription Drug Program. Medicare Part D Medicare Part D prescription drug coverage is available to everyone with Medicare. The Medicare prescription drug coverage is insurance provided by private companies that have been approved by Medicare. The prescription drug coverage and the private companies that offer the coverage vary depending upon where you live. You pay an additional monthly premium for the Medicare prescription drug coverage, and the premium amount varies depending on the coverage you select. The prescription drug coverage under the Blue Cross and Blue Shield Service Benefit Plan is, on average, expected to pay as much as or more than the standard Medicare Part D prescription drug coverage. As long as you keep your Service Benefit Plan coverage, you do not have to enroll in Medicare Part D. However, if you do decide to enroll in Medicare Part D, you can keep your Service Benefit Plan coverage and we will coordinate benefits with Medicare. See Section 10 in the 2008 Service Benefit Plan brochure for information about how we coordinate benefits. It is important that you keep your Service Benefit Plan coverage, regardless of your decision, to cover other medical expenses. In addition, if you are an annuitant and terminate your FEHB coverage, you may not re-enroll in any FEHB coverage, including the Service Benefit Plan. You can get more information about Medicare Part D and the coverage offered in your area at www.medicare.gov, or you can call Medicare at 1.800.633.4227. TTY users can call 1.877.486.2048. Benefits Are Different In Special Circumstances If you purchase prescription drugs from physicians or providers that are not retail pharmacies, you are also entitled to benefits for these medications. But remember that these expenses may be counted toward your annual deductible under Standard Option and the benefits are different, too.* You or the provider should file your claim to your local Blue Cross and Blue Shield Plan. * If Medicare Part B is your primary carrier for your medical expenses, the Standard Option annual deductible copayment and coinsurance amounts are waived and you are reimbursed in full. Under Basic Option, you must use Preferred providers except in certain situations such as emergency care. |
