Premera Blue Cross Medicare Advantage Formulary

Understanding Your Medicare Advantage Formulary

When you enroll in a Premera Blue Cross Medicare Advantage plan, you gain access to comprehensive prescription drug coverage through the plan's formulary. The formulary is a list of prescription drugs that are covered by your plan, including both brand name and generic medications. Understanding how this formulary works can help you maximize your benefits while managing your healthcare costs effectively.

Premera's Medicare Advantage formularies are designed to provide you with the most effective medications at reasonable costs. The formulary includes most of the medications that Medicare Part D plans typically cover, while also ensuring that you have access to FDA-approved treatments for your health conditions.

Drug Tiers and Cost Structure

The Premera Blue Cross Medicare Advantage formulary organizes medications into tiers, with each tier having a different cost structure. This tiered system helps manage costs while ensuring access to necessary medications.

Note: Specific costs and copay amounts may vary depending on your particular Premera Medicare Advantage plan and the year.

Specialty Medications

Specialty drugs are typically high-cost medications used to treat complex conditions such as cancer, rheumatoid arthritis, multiple sclerosis, and hepatitis. These medications often require special handling, administration, or monitoring. In the Premera Blue Cross Medicare Advantage formulary, specialty drugs are generally placed in Tier 5 and may have different cost-sharing arrangements than lower-tier medications.

For many specialty medications, you may need to use a specialty pharmacy designated by Premera. These pharmacies specialize in delivering, storing, and handling specialty medications and can provide additional support services for patients taking these complex therapies.

Formulary Changes and Updates

It's important to understand that the Premera Blue Cross Medicare Advantage formulary may change during the year. Changes might include:

• Adding new medications to the formulary
• Moving medications to different tiers
• Removing medications from the formulary
• Adding, modifying, or removing prior authorization requirements

Prior Authorization and Coverage Rules

Certain medications in the Premera Blue Cross Medicare Advantage formulary may require prior authorization. This means your doctor needs to get approval from Premera before the medication will be covered. Prior authorization is typically required for medications that:

• Have potential safety concerns
• Have a less expensive alternative that may be equally effective
• Are typically prescribed for conditions not covered by Medicare
• Are part of a step therapy protocol

Step therapy is another coverage rule that may apply to certain medications. With step therapy, you may need to try a less expensive medication first before the plan will cover a more costly drug. This is typically applied when there is evidence that the step therapy drug is as effective as the targeted medication for your condition.

Quantity Limits and Drug Management

Some medications in the Premera Blue Cross Medicare Advantage formulary may have quantity limits. These limits are designed to ensure safe and appropriate use of medications and to control costs. Quantity limits specify the maximum amount of a medication that can be dispensed within a certain time period (typically 30 or 90 days).

If you believe you need a medication in a quantity that exceeds the limit, your doctor can request an exception. When making this request, your doctor should provide documentation explaining why the standard quantity is not sufficient to treat your condition.

Appeals and Exceptions

If your medication is not on the formulary, is restricted by prior authorization or step therapy, or you need an exception to a quantity limit, you have the right to request an appeal or exception. The process typically involves:

1. Having your doctor submit a request to Premera explaining why you need the medication
2. Providing medical documentation supporting the request
3. Receiving a decision from Premera, typically within 72 hours for standard requests and 24 hours for expedited requests
4. Having the right to appeal if the request is denied

Remember that you can continue to receive your current medication while your request is being reviewed, and during the appeal process if you request a continuation of benefits.

Accessing Formulary Information

Premera provides several ways to access information about your Medicare Advantage formulary:

• Online: Visit the Premera Blue Cross website and log into your member portal to view the complete formulary
• Mobile App: Download the Premera mobile app to search for medications and check coverage while on the go
• Customer Service: Call Premera's member services to speak with a representative who can answer questions about your formulary
• Printed Directory: Request a printed copy of the formulary to be mailed to your home

Annual Enrollment Period

Each year during the Medicare Annual Enrollment Period (October 15 to December 7), you have the opportunity to review and adjust your Medicare Advantage coverage. This is a good time to:

• Review the formulary for any changes to medications you take
• Compare your current plan's formulary with other available plans
• Determine if your current plan still provides the best value for your prescription needs

Medication Therapy Management

Premera Blue Cross Medicare Advantage plans may offer Medication Therapy Management (MTM) programs for eligible members. These programs provide one-on-one consultations with pharmacists to help you understand your medications, identify potential drug interactions, and develop strategies to improve medication adherence. Eligibility for MTM programs is typically based on factors such as:

• The number of chronic conditions you have
• The number of different medications you take
• Your annual prescription drug costs

If you qualify for an MTM program, Premera will contact you with information about how to participate.

Prefered Pharmacies and Cost Savings

Many Premera Blue Cross Medicare Advantage plans have a network of preferred pharmacies that offer lower copayments for prescription medications. Using a preferred pharmacy can help reduce your out-of-pocket costs on medications. These pharmacies may include:

• Retail pharmacy chains
• Independent community pharmacies
• Home delivery pharmacies (mail order)
• Specialty pharmacies for certain medications

Mail order pharmacies often provide additional cost savings and the convenience of having medications delivered to your home, typically in 90-day supplies for maintenance medications.