If your drug is not included in the formulary, call customer service at 888-850-8526 (TTY/TDD: 711) Monday to Friday, 8 a.m. to 8 p.m., (or 7 days a week, 8 a.m. to 8 p.m., October 1 to 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:

• 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:

• Ask us to cover a drug even if it's not on our covered drug list.
• 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.
• Ask us to waive coverage restrictions or limits on the 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.

Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year, with these exceptions:

• When a new, less expensive generic drug becomes available.
• When new information about the safety or effectiveness of a drug is released.
• The drug is removed from the market.

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 formulary 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 formulary, 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 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.

As a new or continuing member, 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 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 one-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 one-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 one-month supply of medication. After your first one-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.

View our transition policy:

• 2024 Medicare Advantage Drug Transition Policy

2024: After the total combined plan and member drug cost equals $5,030, 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 25% of the price for generic drugs until your total out-of-pocket costs reach $8,000.

Your plan may require you to try an effective but more affordable drug to treat your condition before covering a more expensive drug. For more information, refer to Premera's Step Therapy Criteria.

• 2024 Step Therapy Criteria (.pdf)

For some covered drugs, you will need to get approval from the plan before you fill your prescriptions. Without approval, your drug may not be covered. For more information, refer to Premera's Prior Authorization Criteria (.pdf).

• 2024 Prior Authorization Criteria (.pdf)

To request approval, complete the Prior Authorization Form (.pdf).

You can read more here about Part D coverage determination, exceptions, appeals, and grievances.

If you don’t enroll in Medicare Part D when you’re first eligible and there’s a continuous period of 63 days or more—and you don’t have creditable coverage through an employer-provided plan—you may have to pay a penalty. For each month you delay, you may pay an additional 1% of the average premium per month in addition to your regular plan premium as long as you are enrolled in a Part D plan. View the Creditable Coverage and Late Enrollment Penalty page on the Centers for Medicare & Medicaid Services (CMS) website.

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 coinsurance. 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, review the Low Income subsidy (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 (TTY/TDD: 711).

• 2024 LIS Premium Summary Table (.pdf)

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.

The pharmacy network for Premera Blue Cross Medicare Advantage (HMO), Classic (HMO), Total Health (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.