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

You can ask your Medicare Advantage plan to make anexception to these restrictions or limits. See the section,“How do I request an exception to the Medicare HMO BlueValueRx and Medicare HMO Blue PlusRx formulary?” onpage 3 for information about how to request an exception.What if my drug is not in the Formulary?If your drug is not included in this formulary, you should firstcontact Member Services and confirm that your drug is notcovered. If you learn that Medicare HMO Blue ValueRx andMedicare HMO Blue PlusRx do not cover your drug, youhave two options:• You can ask Member Services for a list of similar drugsthat are covered by Medicare HMO Blue ValueRx andMedicare HMO Blue PlusRx. When you receive the list,show it to your doctor and ask him or her to prescribea similar drug that is covered by Medicare HMO BlueValueRx and Medicare HMO Blue PlusRx.• You can ask Medicare HMO Blue ValueRx and MedicareHMO Blue PlusRx to make an exception and coveryour drug. See below for information about how to requestan exception.How do I request an exception to the Medicare HMOBlue ValueRx and Medicare HMO Blue PlusRx Formulary?You can ask Medicare HMO Blue ValueRx and MedicareHMO Blue PlusRx to make an exception to our coveragerules. There are several types of exceptions that you canask us to make.• You can ask us to cover your drug even if it is not onour formulary.• You can ask us to waive coverage restrictions or limits onyour drug. For example, for certain drugs, Medicare HMOBlue ValueRx and Medicare HMO Blue PlusRx limit theamount of the drug that we will cover. If your drug hasa quantity limit, you can ask us to waive the limit andcover more.• You can ask us to provide a higher level of coverage foryour drug. This would lower the amount you must pay foryour drug. If your drug is contained in our non-preferredbrand tier, you can ask us to cover it at the cost-sharingamount that applies to drugs in the preferred brand tierinstead. Please note, if we grant your request to cover adrug that is not on our formulary, you may not ask us toprovide a higher level of coverage for the drug. Also,you may not ask us to provide a higher level of coveragefor drugs that are on the Tier 5 Specialty tier.Generally, Medicare HMO Blue ValueRx and MedicareHMO Blue PlusRx will only approve your request for anexception if the alternative drugs included on the plan’sformulary, or the lower-tiered drug or additional utilizationrestrictions would not be as effective in treating your conditionand/or would cause you to have adverse medical effects.You should contact us to ask us for an initial coveragedecision for a formulary, tiering or utilization restrictionexception. When you are requesting a formulary, tieringor utilization restriction exception you should submit astatement from your physician supporting your request.Generally, we must make our decision within 72 hours ofgetting your prescriber’s or prescribing physician’s supportingstatement. You can request an expedited (fast) exception ifyou or your doctor believe that your health could be seriouslyharmed by waiting up to 72 hours for a decision. If yourrequest to expedite is granted, we must give you a decisionno later than 24 hours after we get your prescriber’s orprescribing physician’s supporting statement.page 3 3