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

The information in the Requirements/Limits columntells you if Medicare HMO Blue ValueRx and MedicareHMO Blue PlusRx have any special requirements forcoverage of your drug.The abbreviations you may see in the drug listing include:Quality Care Dosing (QCD): To help ensure thatthe quantity and dosage of your medications remainsconsistent with manufacturer, clinical, and Food and DrugAdministration (FDA) recommendations, we maintain a listof medications subject to QCD. When you fill a prescriptionfor a medication subject to QCD, your prescription isreviewed for:• Dose Consolidation. Dose consolidation checks to seewhether you’re taking two or more daily doses of medicinethat could be replaced with one daily dose providing thesame total amount of medication.• Recommended Monthly Dosing Level. This process checksto see that your monthly dosage of medication is consistentwith both the manufacturer’s and the FDA’s monthlydosing recommendations and clinical information.Your doctor can also apply for an exception to QCDguidelines when medically necessaryNo Mail Order (NMO): These prescription drugs are notavailable through mail-order.Home Infusion Therapy (HIT): These prescription drugsmay be covered under our medical benefit.Medical Benefit (MB): These drugs and supplies are coveredunder your plan’s medical benefit and are available throughnetwork retail pharmacies or mail-order service.*Limited Pharmacy Availability (LPA): These prescriptionsmay be available only at certain pharmacies.How much will I pay for my Medicare Advantage plan’scovered drugs?Your Medicare prescription drug costs:The amount you pay depends on which drug tier yourdrug is in under our plan. You can find out which drug tieryour drug is in by looking in the formulary included in thisbooklet. See the next page for the copayment/co-insuranceamount for each type of drug.If you qualify for extra help with your drug costs, your costsfor your drugs may be different than those described on thenext page. Please refer to the plan Summary of Benefits oryour Evidence of Coverage, or call Member Service to findout what your costs are.Your costs for drugs and supplies covered under your plan’smedical benefit:You will find some drugs and supplies listed in the formularydrug list with a “MB” note in the tier column. These drugsand supplies covered under your plan’s medical benefit areavailable through network retail pharmacies or mail-orderservice. However, they do not qualify for exception requests,extra help on drug costs, transition fills, or accumulate towardyour total out of pocket costs to bring you through thecoverage gap faster like drugs covered under your Medicareprescription drug benefit.You pay nothing for these drugs and supplies covered underyour plan’s Original Medicare medical benefit.* This formulary booklet lists certain brand test strips;however all other brands of test strips are also covered.page 5 5