Want help? Call 855-339-5205 (TTY/TDD: 711)

Prescription Drug Documents and Forms

Prescription drug documents and forms

  • Find a Pharmacy

    With a network this big, your pharmacy may already participate.

    Our plans give you access to an extensive network of local and national pharmacies that work with Premera Blue Cross Medicare Advantage to keep your costs low.

    You may choose to have your prescriptions delivered to your home using our mail order pharmacy home delivery services. You can fill a long term supply* of some medications using our mail order pharmacy or at many of the retail pharmacies in our network. If you would like to have a printed copy of the pharmacy directory mailed to you instead of using the online pharmacy tool, please call 888-850-8526 (TTY/TDD: 711) Monday – Friday, 8 a.m. – 8 p.m., (7 days a week, 8 a.m. – 8 p.m., October 1 – March 31).

    For 2019 plans, find a pharmacy

    The pharmacy network for Premera Blue Cross Medicare Advantage (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) and Core (HMO) includes pharmacies that offer standard cost-sharing and pharmacies that offer preferred cost-sharing. Members of these plans may go to either type of network pharmacy to receive covered prescription drugs. Your cost-sharing may be less at pharmacies with preferred cost-sharing.

    *Long Term Supply

    For members in Premera Blue Cross Medicare Advantage (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) and Core (HMO), a long term supply is a 90-day supply.

    For members in Premera Blue Cross Medicare Advantage Sound + Rx (HMO), Peak + Rx (HMO), Charter + Rx (HMO), a long term supply is a 93-day supply.

  • Part D Drug Costs

    Premera Blue Cross Medicare Advantage Plans are available to residents of King, Lewis, Pierce, Skagit, Snohomish, Spokane, Stevens, Thurston, and Whatcom counties in Washington.

  • Coverage gap stage:

    2019


    After the total combined plan and member drug cost equals $3,820, the coverage gap starts. During this stage, you will pay 25% of the price for brand name drugs (plus a portion of the dispensing fee) and 37% of the price for generic drugs until your total out-of-pocket costs reach $5,100.

     

  • Catastrophic coverage stage:

    2019


    After your yearly out-of-pocket costs reach $5,100 (including your retail and mail order pharmacy), you pay the greater of:

     

    • Coinsurance of 5% of the cost of the drug, OR
    • $3.40 for a generic drug (or drug that is treated like a generic) and $8.50 for all other drugs.

    Coverage level shown does not reflect standard pharmacy cost shares or mail-order pharmacy cost shares. Please refer to the 2019 Summary of Benefits for additional coverage details.

    Premera Blue Cross Medicare Advantage Core (HMO) – Skagit and Whatcom counties

    Premera Blue Cross Medicare Advantage (HMO), Total Health (HMO) – Spokane and Stevens counties

    Premera Blue Cross Medicare Advantage (HMO), Classic (HMO), Classic Plus (HMO) – King, Pierce, Snohomish, Thurston, and Lewis counties

    Premera Blue Cross Medicare Advantage Alpine (HMO), Charter + Rx (HMO) – King, Pierce, Snohomish, Thurston, and Whatcom counties

    Premera Blue Cross Medicare Advantage Peak + Rx (HMO), Sound + Rx (HMO) – King, Pierce, Snohomish, Thurston, and Whatcom counties

General Pharmacy Information

  • Part D pharmacy resources

    Medications can play a significant role in your health care. The following information will help guide your decisions about medications and answer questions about your Medicare pharmacy benefits.

  • Customer Service

    For assistance with pharmacy-related questions, please call Premera Blue Cross Medicare Advantage Customer Service. We will be happy to help you, please call 888-850-8526 (TTY/TDD: 711) Monday – Friday, 8 a.m. – 8 p.m., (7 days a week, 8 a.m. – 8 p.m., October 1 – March 31).

  • Formulary (list of covered drugs)

    Premera Blue Cross Medicare Advantage Plans use a List of Covered Drugs. This drug list is the Premera Comprehensive Formulary and is a complete list of drugs covered by Premera Blue Cross Medicare Advantage Plans. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. A copy of the formulary can be found on the Medicare Forms page on this website. You may also use an interactive drug list look up tool at the link below.

    If you would like to have a printed copy of the formulary mailed to you instead of using the online tools, please call 888-850-8526 (TTY/TDD: 711) Monday – Friday, 8 a.m. – 8 p.m., (7 days a week, 8 a.m. – 8 p.m., October 1 – March 31).

    2019 list of covered drugs (formulary)

  • Formulary changes

    Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market

    Below are changes to the drug list that will affect members currently taking a drug:

    New generic drugs.We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you.

    Drugs removed from the market.If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

    Other changes.We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective.

    Information on formulary changes can be found on the Medicare Forms page on this website.

  • What if my drug is not covered?

    If your drug is not included in the covered drug list call Customer Service at 888-850-8526 (TTY/TDD: 711) Monday – Friday, 8 a.m. – 8 p.m., (7 days a week, 8 a.m. – 8 p.m., October 1 – March 31), and ask if your drug is covered.

    If you learn that Premera Blue Cross Medicare Advantage plans do not cover your drug, you can take any of the following steps:

    • Talk to your doctor about alternative drugs that are on the formulary.
    • Seek a formulary exception.

    There are several types of formulary exceptions that you can ask us to make:

    • You can ask us to cover a drug even if it's not on our covered drug list.
    • You can ask us to cover a drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
    • You can ask us to waive coverage restrictions or limits on our drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount

    For more information on how to request an exception, please see Part D Coverage Determinations, Exceptions, Appeals, and Grievances.

  • Transition (temporary supply)

    As a new or continuing member in our plan, you may be taking drugs that are not on our formulary (which is the list of drugs covered on your plan), or you may be taking a drug that is on our formulary, but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an alternative drug that we cover or request a formulary exception. If a formulary exception request is approved, we will cover the drug you take, even though it is not on the formulary.

    While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. This is called a transition supply of drugs.

    Here’s how a transition supply is provided to you for each of your drugs not on our formulary or for your covered drugs that are available only with limits, such as prior authorization:

    New members - we will cover a temporary month* supply within the first 90 days you are a member of the plan;

    Current members who are experiencing a negative formulary change year over year - we cover a temporary month* supply during the first 90 days of the new plan year.

    If your prescription is written for fewer days, we will allow refills to provide up to a maximum month* supply of medication. After your first month* supply, we will not pay for these drugs, even if you have been a member of the plan fewer than 90 days.

    If you live in a long-term care facility, we’ll provide an emergency supply of any drug you need that’s not on our formulary or any drug that’s covered but with limits. If you’re past the first 90 days of membership in our plan, we’ll cover a 31-day emergency supply of that drug while you pursue a formulary exception.

    2019 Medicare Advantage Drug Transition Policy

    *Month Supply

    For members in Premera Blue Cross Medicare Advantage (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) and Core (HMO), a month transition supply for non-LTC pharmacies is a maximum of a 30-day supply.

    For members in Premera Blue Cross Medicare Advantage Sound + Rx (HMO), Peak + Rx (HMO), Charter + Rx (HMO), a month transition supply for non-LTC pharmacies is a maximum of a 31-day supply.

  • Pharmacies (pharmacy network)

    Search our accurate, up-to-date database to see if your pharmacy is in our network. Premera Blue Cross Medicare Advantage Plans have contracts with pharmacies that equal or exceed the Centers for Medicare and Medicaid (CMS) requirements for pharmacy access in your area. Our plans give you access to an extensive network of local and national pharmacies that work with Premera Blue Cross Medicare Advantage to keep your costs low.

    You may choose to have your prescriptions delivered to your home using our mail order pharmacy home delivery services. You can fill a long term supply* of some medications using our mail order pharmacy or at many of the retail pharmacies in our network.

    The pharmacy network for Premera Blue Cross Medicare Advantage (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) and Core (HMO) includes pharmacies that offer standard cost-sharing and pharmacies that offer preferred cost-sharing. Members of these plans may go to either type of network pharmacy to receive your covered prescription drugs. Your cost-sharing may be less at pharmacies with preferred cost-sharing.

    The directory will tell you which of the network pharmacies offer preferred cost-sharing. It will also tell you what retail pharmacies can fill a long term supply* of medication. You can also contact Customer Service if you need help finding a network pharmacy near you.

    2019 Find a pharmacy

    *Long Term Supply

    For members in Premera Blue Cross Medicare Advantage (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) and Core (HMO), a long term supply is a 90-day supply.

    For members in Premera Blue Cross Medicare Advantage Sound + Rx (HMO), Peak + Rx (HMO), Charter + Rx (HMO), a long term supply is a 93-day supply.

  • Mail-order pharmacies

    You may choose to have your prescriptions delivered to your home using our mail order pharmacy home delivery services. You can fill a long term supply* of some medications using our mail order pharmacy or at many of the retail pharmacies in our network.

    Order form for requesting prescriptions at the mail order pharmacy

    *Long Term Supply

    For members in Premera Blue Cross Medicare Advantage (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) and Core (HMO), a long term supply is a 90-day supply.

    For members in Premera Blue Cross Medicare Advantage Sound + Rx (HMO), Peak + Rx (HMO), Charter + Rx (HMO), a long term supply is a 93-day supply

  • About out-of-network pharmacies

    We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. The circumstances when we would cover prescriptions filled at an out-of-network pharmacy are listed below. Before you fill your prescription in these situations, call Customer Service to see if there is a network pharmacy in your area where you can fill your prescription.

    • You are traveling outside the service area and run out of or lost your covered Part D drugs or become ill and need a covered Part D drug.
    • You are unable to obtain a covered drug in a timely manner at a network pharmacy in your service area (for example no access to 24 hour/7 day a week network pharmacy).
    • You are unable to obtain a particular drug as it is not regularly stocked at an accessible network pharmacy or mail order pharmacy (for example orphan or specialty drug with limited distribution).
    • The network mail-order pharmacy is unable to get the covered Part D drug to you in a timely manner and you run out of your drug.
    • Drug is dispensed to you by an out-of-network institution-based pharmacy while you are in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting.
    • During any Federal disaster declaration or other public health emergency declaration in which you are evacuated or otherwise displaced from your place of residence and cannot be reasonably expected to obtain your covered Part D drugs at a network pharmacy.

    We will cover prescriptions that are filled at an out-of-network pharmacy for medical emergencies and in some routine situations for up to a month supply. Drugs excluded by federal statute from the Medicare Part D formulary are not eligible for coverage even in emergency or urgent situations.

    *Month Supply

    For members in Premera Blue Cross Medicare Advantage (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) and Core (HMO), a month supply is a maximum of a 30-day supply.

    For members in Premera Blue Cross Medicare Advantage Sound + Rx (HMO), Peak + Rx (HMO), Charter + Rx (HMO), a month supply is a maximum of a 31-day supply.

  • Requesting reimbursement for a prescription drug

    If you do go to an out-of-network pharmacy for the reasons listed above, you will generally have to pay the full cost (rather than paying just coinsurance or copayment) when you fill your prescription.

    You may ask us to reimburse you for our share of the cost by submitting a paper claim. Send us your request for payment, along with your bill and documentation of any payment you have made. It's a good idea to make a copy of your bill and receipts for your records.

    Mail your request for payment together with any bills or receipts to us at this address:
    CVS Caremark
    P.O. Box 52066
    Phoenix, AZ 85072-2066

    Contact Customer Service if you have any questions on submitting a paper claim.

    You should submit a claim to us if you fill a prescription at an out-of-network pharmacy because any amount you pay for a covered Part D drug helps you qualify for catastrophic coverage. If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.

  • What if my pharmacy leaves the network?

    If the pharmacy you have been using leaves the plan's network, you will have to find a new pharmacy that is in the network. If the pharmacy you have been using stays within the network but is no longer offering preferred cost-sharing, you may want to switch to a different pharmacy. To find another network pharmacy in your area, go to premera.com/ma and click on find a pharmacy, or call Customer Service at 888-850-8526 (TTY/TDD: 711) Monday – Friday, 8 a.m. – 8 p.m., (7 days a week, 8 a.m. – 8 p.m., October 1 – March 31).

  • Medication Therapy Management program

    Premera Blue Cross Medicare Advantage Plans' Medication Therapy Management (MTM) program helps ensure your medications are working to improve your health. The MTM program is a service offered by Premera Blue Cross Medicare Advantage Plans to its members and is not considered a benefit. For more details, please see the MTM page.

  • Part D coverage determinations, exceptions, appeals, and grievances
  • Other important information:
  • Contact us

    Sales: 888-868-7767 (TTY/TDD: 711)
    Monday – Friday, 8 a.m. – 8 p.m., (7 days a week, 8 a.m. – 8 p.m., October 1 – March 31).

    Customer service: 888-850-8526 (TTY/TDD: 711)
    Monday – Friday, 8 a.m. – 8 p.m., (7 days a week, 8 a.m. – 8 p.m., October 1 – March 31).

    Premera Blue Cross Medicare Advantage Plans
    P.O. Box 262548
    Plano, TX 75026

  • Extra help

    The government subsidizes prescription drug costs for members with limited incomes. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to 100% of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't know it. For more information about this Extra Help see the LIS Premium Summary Table, contact your local Social Security office, or call 800-MEDICARE (800-633-4227), 24 hours per day, 7 days per week. TTY/TTD users should call 877-486-2048.

  • Best available evidence

    CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate in CMS's systems. View the CMS Best Available Evidence Policy Information on the CMS website.

  • Late enrollment penalty

    Medicare beneficiaries may incur a late enrollment penalty (LEP) if there is a continuous period of 63 days or more at any time after the end of the individual's Part D initial enrollment period during which the individual was eligible to enroll, but was not enrolled in a Medicare Part D plan and was not covered under any creditable prescription drug coverage. View the Creditable Coverage and Late Enrollment Penalty page on the CMS website.

Medicare beneficiaries may also enroll in Premera Blue Cross Medicare plans through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

© 2018 Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association serving businesses and residents of Alaska and Washington state, excluding Clark County. Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in Premera Blue Cross depends on contract renewal. This information is not a complete description of benefits. Call 888-868-7767 (TTY/TDD: 711) 7 days a week, 8 a.m. to 8 p.m. for more information. To join a Premera Blue Cross Medicare Advantage Plan, you must have Medicare Part A and Part B and live in the Premera Blue Cross Medicare Advantage service area (King, Pierce, Lewis, Skagit, Snohomish, Spokane, Stevens, Thurston, and Whatcom counties in Washington). Members must select a Primary Care Provider (PCP) from the Premera Blue Cross Medicare Advantage Plans provider network. For accommodation of persons with special needs at sales meetings, call 888-868-7767 (TTY/TDD: 711), 7 days a week, 8 a.m. to 8 p.m.