2012 Medicare plans (Switch plan year)

Transition policy

Compare our plans
Enroll now

Blue Cross Blue Shield of Michigan provides a transition process that allows members to receive a temporary supply of non-formulary drugs or to request a formulary exception on the grounds of medical necessity. This process meets the immediate needs of our members and provides sufficient time for them to work with their health care providers to switch to a therapeutically equivalent formulary medication or to complete the formulary exception process. The transition policy applies to Part D drugs that are not on BCBSM's formulary — and to Part D drugs that are on BCBSM's formulary, but require prior authorization or step therapy under the Blues' utilization management rules.

The transition policy applies to members in various settings:

Retail or mail pharmacy setting

A temporary 31-day supply (unless the prescription is written for less than a 31-day supply) of non-formulary drugs will be provided anytime during the 90-day transition period.

Long-term care setting

Multiple fills of a temporary 31-day supply (unless the prescription is written for less than a 31-day supply) will be provided during the 90-day transition period. BCBSM will honor multiple fills of non-formulary Part D drugs for up to a 93-day supply within the first 90 days of coverage in a BCBSM plan.

Level of care changes

An emergency transition supply will be provided to current long-term care enrollees who enter into a facility from another care setting. This transition supply is not limited to initial enrollment only.

Emergency supply

After the 90-day transition period expires, BCBSM will also provide a 31-day transition supply to current long-term care enrollees who require an emergency supply of a non-formulary drug. The emergency supply will be granted while the enrollee's exception or prior authorization is being processed.

The transition policy applies to the following enrollees:

The transition period begins on the enrollee's effective date of coverage under the plan. Each enrollee who receives a transition supply will be sent a written notice via first-class U.S. mail. The notice will be sent within three days of the temporary fill. The notice will include:

Formulary exception request forms will be available to members, appointed representatives and physicians via mail, fax, e-mail and our website.

To determine the proper course of action, Medical review of non-formulary drug requests may be required for enrollees receiving a temporary supply of a Part D drug under this policy. BCBSM will work with the enrollee's physician to gather appropriate clinical history to facilitate the non-formulary drug request or the switch to a therapeutically appropriate formulary alternative.

Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a non-Part D drug or a drug out-of-network, unless you qualify for out-of-network access. See your Evidence of Coverage for information about non-Part D drugs.

H9572 S5584_W_12BCBSMAdvantageWebR2 CMS Approved 04262012

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to seventy-five (75) percent 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 even know it. For more information about the Extra Help program, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days per week. TTY users should call 1-877-486-2048.

Important information about these plans

Medicare Plus Blue PPOSM is a health plan with a Medicare contract. Prescription Blue PDPSM is a stand-alone prescription drug plan with a Medicare contract.

Medicare Plus Blue PPO

Medicare Plus Blue PPO is available to all Medicare beneficiaries who are Michigan residents and are entitled to receive services under Medicare Part A and enrolled in Part B.

With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare allowed amount and the contracted amount is lower. You may receive services from any provider who accepts Original Medicare. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit www.bcbsm.com/medicare/provdirectory.shtml.

Prescription Blue PDP

Prescription Blue PDP is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B.

Medicare Plus Blue PPO and Prescription Blue PDP

Premiums vary by county. You must continue to pay your Medicare Part B premium.

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,300 Michigan retail pharmacies, of which 86 percent are network pharmacies. Nationwide, most chain pharmacies are in our network, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies.

In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost sharing amount if you get your drugs at an out-of-network pharmacy. Quantity limitation and restrictions may apply. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Member Services at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X435, Detroit, MI 48226.

If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on Jan. 1, 2013.

Medicare beneficiaries may enroll in Medicare Plus Blue PPO, BCN Advantage HMO-POS or Prescription Blue PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704.

You may only enroll in Medicare Plus Blue PPOSM or Prescription Blue PDPSM during specific times of the year. To learn more about enrollment periods, please contact Member Services.