Pharmacy Benefits

 

We offer two ways to receive pharmacy benefits:

  • Enroll in a Blue Cross Medicare Advantage Plan—the pharmacy benefits are automatically included.
  • If you get Medicare benefits through Medicare Part A and Part B, you can enroll in a Blue Cross Prescription Dug Plan to receive pharmacy benefits.

Medicare Advantage Plans

Medicare Advantage Pharmacy Benefits

Use the menus below to learn about pharmacy benefits.

From the Express Scripts Pharmacy to Your Door

If you're taking a medicine on a long-term basis, using our mail-order home delivery service could save you time and money. Standard shipping is free, and a 90-day supply of drugs will usually cost less than buying them at the retail pharmacy. Some prescriptions aren't available by mail order, but millions of people get the medicine they need using this service.

Express Scripts will:

  • Ship your medicine straight to your door

  • Let you know when it's time to refill your prescription

  • Call your doctor to change or renew your prescription

You get to:

  • Skip a trip to the pharmacy

  • Talk to a pharmacist anytime, 24/7, from the privacy of your home

  • Get real-time status updates on your prescription orders

  • Order refills with just one click

  • View your monthly prescription summary online and go paperless

  • View your total out-of-pocket drug costs for the year

Getting Started

Starting home delivery is easy—just go to Express Scripts and register. When you log into your account, you'll be able to:

  • Quickly fill prescriptions your doctor has sent in electronically 

  • Order a refill

  • Check the status of orders

  • Find savings opportunities

Home Delivery Resources

  • Express Scripts Mobile App Download the free Express Scripts mobile app from the App Store or Google Play.

  • Mail - Download, print, and mail a home delivery order form. Include your home delivery copayment, a 90-day prescription from your doctor plus refills for up to one year (if applicable).

  • ePrescribe - Ask your doctor to send your prescription electronically to the Express Scripts Pharmacy.

Note: If you're not taking a long-term medicine now, check back if your doctor prescribes one to maintain your health. However, if you're taking a medicine every day over the long term, the Express Scripts Pharmacy is a mail order service that could help you save over retail prices.

First-Time Users

First time users of mail order service should expect their first order within 14 calendar days after the pharmacy receives an order, however, be sure to ask your prescriber for a 2nd script for short term fill locally to ensure you have enough supply. 

If your medications do not arrive within 14 days, please call  1-800-820-9729 (TTY:1-800-716-3231) 24 hours a day, 7 days per week.

Required Consent

If you have not used mail-order pharmacy in the last 365 days, Express Scripts must obtain member consent for any prescriber-initiated orders, meaning the script was sent to pharmacy on behalf of member via fax, phone, or electronically.

Automatic Refills and Renewals Not Included

Automatic refill or Automatic renewal services are excluded from Medicare plans. If you have been participating in this program prior to aging into Medicare, you will receive one last fill as you transition and a letter of notification.

Questions? 

If you have questions, call 1-800-820-9729 (TTY: 1.800.716.3231), 24 hours a day, 7 days a week, to talk with a prescription plan specialist at any time. 

You can also get started with home delivery by using our mobile app or send in orders through the mail.

A formulary is a list of covered drugs under a Medicare Advantage Part D Plan. The list includes both brand-name and generic drugs. We have a team of doctors and pharmacists—our Pharmacy and Therapeutics Committee (P&T)—who review our lists of covered medications (formularies) for safety and effectiveness. Based on recommendations from our P&T Committee, we occasionally make changes to the medications covered by our formulary.

Medications on the formulary may change for the following reasons:

  • New medications become available and may be added to the formulary.

  • Brand-name medications become available as generic. As generic medications become available, the corresponding brand-name medications may be removed from the formulary.

  • New pharmacy management programs such as prior authorization, step therapy, or quantity limits are adopted for select medications.

In some cases, if you are already taking a medication when its coverage changes, you will be exempt from those changes for the remainder of the plan year. The exception to this exemption is when a generic medication replaces a brand-name medication in the formulary. When that occurs, we'll notify you, in writing, 60 days before the change takes effect. However, the notice period is waived when a medication is removed for safety reasons.

 

Learn more:

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. This ensures that our members safely use their medications. 

The types of additional requirements are:

  • Prior authorization (prior approval) – For certain drugs, your doctor or health care provider will need to contact us before you fill your prescription.
  • Step therapy – For certain drugs, we require you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

Prior Authorization & Step Therapy Criteria

To see a complete list of drugs that require prior authorization or step therapy or have dosing limits, view the documents below:

If a drug you are taking requires prior authorization or step therapy from the Plan, please download and complete the and ask your doctor to fax it to us at 1-617-246-8506.

We may add or remove drugs from our formulary during the year. If we make changes, we must notify members who take the drug that it will be removed at least 60 days before the date that the change becomes effective, or at the time the member requests a refill of the drug. 

This includes when we: 

  • Remove drugs from our formulary 
  • Add prior authorization 
  • Quantity limits and/or step therapy restrictions on a drug 
  • Or, move a drug to a higher cost-sharing tier 

 

If the Food and Drug Administration (FDA) determines that a drug on our formulary is 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.

 

If your medication is no longer covered by your Medicare Advantage plan, you have two options:

  • You can ask Member Services for a list of similar drugs that are covered by your Medicare Advantage plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by your plan.

  • You can ask your Medicare Advantage plan to make an exception and cover your drug.

 

Contact Us

Contact Member Service at 1-800-200-4255 (TTY: 711), 8:00 a.m. to 8:00 p.m. ET as follows: from February 15 through September 30, Monday through Friday, and from October 1 through February 14, seven days a week, for information about how to request an updated coverage determination or an exception to a coverage determination.

Medicare Advantage Pharmacy Network

Our Medicare Advantage plans have contracts with 1,200 pharmacies in Massachusetts and over 67,900 pharmacies in our nationwide network. The link below provides a list of participating pharmacies.

*Note: Pharmacies may have moved, closed, or may have been added or removed from the list after this directory was printed.

 

Medicare Advantage Plans Network Pharmacies

Get current information about our Medicare Advantage plans' network pharmacies in your area:

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  • Online: Use our online pharmacy search tool. 

  • By Phone: Call our Member Service department at 1-800-200-4255, from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday; and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week. TTY/TDD: 711.

The pharmacies listed in this network may differ from those in the Blue MedicareRxSM (PDP) network—for more information visit Blue MedicareRx (PDP).

In most cases, your prescriptions are covered under our Medicare Advantage plans only if they are filled at a network pharmacy or through our mail-order pharmacy service, Express Scripts

We'll fill prescriptions at non-network pharmacies under certain circumstances as described in your Evidence of Coverage.

 

Other prescription-related information you may need:

Plan Drug Transition Policy

We have a transition plan in place for members who take medications that aren't covered by their plan’s formulary. A formulary is a list of medications that a plan covers.

 

Talk to Your Doctor 

If this situation applies to you, the first step is to talk to your doctor about whether you could switch to a medication that is covered by your plan. To give you and your doctor time to decide, our transition drug policy could allow your current medication to be covered during the first 90 days of your plan membership.

 

Temporary Supply 

For each of your medications that isn't on our formulary, we'll cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we won't pay for these drugs, even if you have been a member of the plan less than 90 days.

 

Emergency Supply

If you need a drug that isn't on our formulary or if your ability to get your drugs is limited, but you're past the first 90 days of membership in our plan, we'll cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days). This will give you time to apply for a drug coverage exception.

 

For Long-term Care Facility Residents 

If you're a resident of a long-term care facility, we'll allow you to refill a prescription until we have provided you with at least a 91-day supply. We'll cover more than one refill of these drugs for the first 90-days you're a member of our plan.

Medication Therapy Management

A Medication Therapy Management (MTM) program is not a benefit, but is a service we offer at no cost. You may be invited to participate in a program designed for your specific health and pharmacy needs. You can decide to not participate, but it's recommended that you take full advantage of this covered service if you're selected.

This program is offered through our partnership with Express Scripts, Inc. (ESI). ESI will contact you when you're eligible. Once enrolled, you'll have the opportunity to speak with a health care professional that will help you to better manage your condition(s).

Program Eligibility

Members must meet all of the three following criteria for enrollment in the MTM program:

  1. Have at least three of the following chronic conditions
    • Asthma/Chronic Obstructive Pulmonary Disease (COPD)
    • Chronic heart failure
    • Diabetes
    • Hypertension
    • Dyslipidemia (high cholesterol)
    • Depression
    • End-Stage Renal Disease (ESRD)
    • Osteoporosis
  2. Must be taking at least seven Part D covered medications
  3. Must spend more than $3,967 a year on Part D covered medications
Comprehensive Medication Review

MTM-eligible members are automatically enrolled in the program and sent an introductory letter that welcomes them to the program, provides the opportunity to opt-out, and offers the opportunity to request a Comprehensive Medication Review (CMR). 

Members may opt-out or request a CMR by returning an enclosed appointment form or calling the provided toll-free number. Members that request a CMR have a telephone appointment scheduled for a one-on-one consultation with a pharmacist or licensed pharmacy intern under the direct supervision of a pharmacist. If the introductory letter is returned via USPS, an attempt will be made via phone call to contact the member in an effort to complete their CMR.

During the CMR, the member's entire medication profile is reviewed (including prescriptions, over the counter drugs (OTCs), herbal supplements, and samples) for appropriateness of therapy. Disease-specific goals of therapy and medication-related problems are discussed with the member, as well as any member-specific questions.

After the CMR, the member is mailed the standardized post-CMR takeaway letter which includes a Personal Medication List (PML) and Medication Action Plan (MAP) detailing the conversation with the pharmacist or licensed pharmacy intern. Meanwhile, all members that have not opted-out of the program receive ongoing Targeted Medication Reviews (TMRs) on at least a quarterly basis with each update of prescription claims.

Be sure to print a blank copy of the Personal Medication List (PML) for your own use.

TMRs identify opportunities for interventions based on systematic drug utilization review including: 

  • Cost savings
  • Adherence to national consensus treatment guidelines
  • Adherence to prescribed medication regimens
  • Safety concerns. 

TMRs that result in the generation of alerts are categorized and prioritized based on the severity of the alert. The member or doctor would then be contacted via phone or mail as appropriate for review of potential therapy changes.

TMR alerts that result in an outbound phone call to the member allow an additional opportunity to offer the member a CMR. Members that accept the CMR on the outbound TMR call receive the CMR as outlined above. Interventions resulting from person-to-person TMRs, non-person-to-person TMRs, and CMRs may result in provider contact via phone call, fax, or mail, when appropriate.

How long does the program last?

The program runs from the time that the member meets eligibility requirements until the end of that calendar year. Eligible participants may be re-enrolled in the program the following January.

If you qualify for the MTM program, you'll receive:

An introductory letter

  • This letter will tell you how to get started.

Comprehensive Medicine Review

  • You'll have the chance to review your medicines with a pharmacist or other health care provider each year. This review will help you get the best results from your medicines.
  • You'll get a letter that outlines this review and suggests action steps.

Targeted Medicine Review

  • You or your doctor will be told if you should consider any changes in your medicines.
  • You or your doctor may receive information that outlines this review.

See Requirements for Medication Therapy Management Programs from CMS.gov.

Contact Us

For more information on the Medication Therapy Management program, please call Member Service at 1-800-200-4255 
(TTY: 711), 8:00 a.m. to 8:00 p.m. ET as follows: from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week.

Prescription Drug Utilization Review

To help ensure that the quantity and dosage of your medications remain consistent with manufacturer, clinical, and the Food & Drug Administration (FDA) recommendations, we maintain a list of medications subject to Quality Care Dosing (QCD). When you fill a prescription for a medication subject to QCD, your prescription is reviewed for:

  • Dose Consolidation – Dose Consolidation checks to see whether you're taking two or more daily doses of medicine that could be replaced with one daily dose providing the same total amount of medication. Dose Consolidation advantages include:
    • Making it more convenient for you to take your medication (you take fewer pills, instead of several doses or pills daily).
    • Helping control overall pharmacy costs.
  • Recommended Monthly Dosing Level – This process checks to see that your monthly dosage of medication is consistent with both the manufacturer's and the FDA's monthly dosing recommendations and clinical information. Your doctor can also apply for an exception to QCD guidelines when medically necessary.
Additional prescription safety and quality measures include:
  • Express Scripts®'', Inc., Medication Alert – Express Scripts, Inc. (ESI) is the prescription mail-order service provider for our Medicare Advantage and Medex®' plans with prescription coverage. When you fill a mail-order prescription, ESI will electronically review it against your previous or current prescriptions. If safety issues are detected, ESI will send an alert to the retail or mail-order pharmacy filling your prescriptions.

Prescription Drug Plans

Blue MedicareRxSM offers two standalone prescription drug plans (PDPs) to residents of Connecticut, Massachusetts, Rhode Island, and Vermont.

Visit the Blue MedicareRx (PDP) website.