2013 Medicare HMO Blue ValueRx/PlusRx Formulary - Blue Cross ...

How do I use the Formulary?There are two ways to find your drug within the formulary:• Medical Condition. The formulary begins on page 7.The drugs in this formulary are grouped into categoriesdepending on the type of medical conditions that theyare used to treat. For example, drugs used to treat a heartcondition are listed under the category, “CardiovascularAgents.” If you know what your drug is used for, look forthe category name in the list that begins on page 7.Then look under the category name for your drug.• Alphabetical Listing. If you are not sure what category tolook under, you should look for your drug in the Index thatbegins on page 96. The Index provides an alphabetical listof all of the drugs included in this document. Both brandname drugs and generic drugs are listed in the Index.Look in the Index and find your drug. Next to your drug,you will see the page number where you can find coverageinformation. Turn to the page listed in the Index and findthe name of your drug in the first column of the list.What are generic drugs?Medicare HMO Blue ValueRx and Medicare HMO BluePlusRx cover both brand name drugs and generic drugs.A generic drug is approved by the FDA as having the sameactive ingredient as the brand name drug. Generally,generic drugs cost less than brand name drugs.Are there any restrictions on my coverage?Some covered drugs may have additional requirementsor limits on coverage. These requirements and limitsmay include:Prior Authorization (PA): Medicare HMO Blue ValueRxand Medicare HMO Blue PlusRx require you to get priorauthorization for certain drugs. This means that you willneed to get approval from Medicare HMO Blue ValueRxand Medicare HMO Blue PlusRx plan before you fill yourprescriptions. If you don’t get approval, your MedicareAdvantage plan may not cover the drug.Quantity Limits (QL): For certain drugs, Medicare HMOBlue ValueRx and Medicare HMO Blue PlusRx limits theamount of the drug that the plans will cover. For example,Medicare HMO Blue ValueRx and Medicare HMO BluePlusRx provide up to 34 tablets per 30 days for a prescriptionof Omeprazole 10 mg capsule.Step Therapy (ST): In some cases, Medicare HMO BlueValueRx and Medicare HMO Blue PlusRx require you tofirst try certain drugs to treat your medical condition beforewe will cover another drug for that condition. For example,if Drug A and Drug B both treat your medical condition,Medicare HMO Blue ValueRx and Medicare HMO BluePlusRx may not cover Drug B unless you try Drug A first.If Drug A does not work for you, Medicare HMO BlueValueRx and Medicare HMO Blue PlusRx will thencover Drug B.You can find out if your drug has any additional requirementsor limits by looking in the formulary that begins onpage 7. You can also get more information about therestrictions applied to specific covered drugs by visiting ourWeb site at www.bluecrossma.com/medicare.2