Medicare Prospects Prescriptions
If you select a Medicare Plan that includes prescription drug coverage, the following information will help you fill your prescriptions.
2016 Drug Lists
The Formulary may change at any time. You will receive notice when necessary.
What is a Formulary?
A formulary is a list of covered drugs selected by us in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
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 except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.
The formulary may change during the year. 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 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. 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.
Some Medicare plans cover both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
Our formulary uses a tiered structure. Drugs in each tier cost different amounts.
If your drug is not on our formulary call our Customer Service Department for a list of similar drugs that are covered on our formulary. Show the list to your doctor and ask him or her to prescribe a similar drug that is covered.
For updated information about the drugs we cover, call Customer Service toll-free at 1-800-499-2838 (TTY/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Feb. 14, representatives also are available weekends from 8 a.m. to 8 p.m.
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the safest, most effective way and also help us control drug plan costs. A team of doctors and/or pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. Please consult our formularies for more information about these requirements and limits.
Drugs that require Prior Authorization, Step Therapy or Quantity Limits are indicated on our drug list. To see if your medication requires Prior Authorization or Step Therapy, or has Quantity Limits, consult the View Our Drug List/Formulary information above.
You can ask us to make an exception to our coverage rules, including waiving our prior authorization, step therapy and quantity limit restrictions on your drug. Learn more about Requesting an Exception below.
Requesting an Exception
If you want to request coverage of a drug not on our formulary, a waiver of our utilization management requirements or your cost-sharing amount, you can request an exception.
Generally, we will only approve your request for an exception if the alternative Part D drugs included on our formulary or the Part D drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
Your doctor must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor should be sent to us with the exception request.
If we approve your exception request, our approval is valid for the remainder of the Plan year, so long as your doctor continues to prescribe the Part D drug for you, and it continues to be safe for treating your condition. If we deny your exception request, you may appeal our decision.
Note: If we approve your exception request for a Part D non-formulary drug, you cannot request an exception to the co-payment or coinsurance amount we require you to pay for the drug.
You may contact us to ask for any of these requests at:
For information on the status of your exception request call Customer Service toll-free at 1-800-499-2838 (TTY/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Feb. 14, representatives also are available weekends from 8 a.m. to 8 p.m.
Your doctor needs to request prior authorization for you using these forms.
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.
Select your plan in your location to learn more:
|Medicare BlueClassic (PPO)||CNY||Broome - Cayuga - Chemung - Chenango - Cortland - Jefferson - Lewis - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins|
|Medicare BlueSecure (PPO)||CNY||Broome - Cayuga - Chemung - Chenango - Cortland - Jefferson - Lewis - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins|
|Medicare BlueEnhanced (PPO)||CNY||Broome - Cayuga - Chemung - Chenango - Cortland - Jefferson - Lewis - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins|
|Medicare BlueEssential (PPO)||CNY|
|Medicare BluePlus (PPO)||East||Clinton - Delaware - Essex - Franklin - Fulton - Hamilton - Montgomery - Otsego|
|Medicare Bassett (HMO-POS)||East||Delaware - Otsego|
|Medicare Blue Choice Value (HMO)||Rochester||Livingston - Monroe - Ontario - Seneca - Wayne - Yates|
|Medicare Blue Choice Value Plus (HMO)||Rochester||Livingston - Monroe - Ontario - Seneca - Wayne - Yates|
|Medicare Blue Choice Optimum (HMO-POS)||Rochester||Livingston - Monroe - Ontario - Seneca - Wayne - Yates|
|Medicare Blue Choice Select (HMO-POS)||Rochester||Livingston - Monroe - Ontario - Seneca - Wayne - Yates|
|Medicare BlueClassic (PPO)||Utica-Rome||Herkimer - Madison - Oneida|
|Medicare BlueSecure (PPO)||Utica-Rome||Herkimer - Madison - Oneida|
|Medicare BlueEnhanced (PPO)||Utica-Rome||Herkimer - Madison - Oneida|
|Medicare BlueEssential (PPO)||Utica-Rome||Herkimer - Madison - Oneida|
|Medicare Bassett (HMO-POS)||Utica-Rome||Herkimer|
Elderly Pharmaceutical Insurance Coverage (EPIC) is a New York State program* for seniors that helps with out-of-pocket Medicare Part D drug plan costs. It works together with Medicare Advantage plans, and over 250,000 New Yorkers have already joined EPIC to save on their prescription drug coverage. EPIC helps pay Medicare Part D drug plan premiums or provides assistance by lowering deductibles. There are two plans based on income:
How to Join the Program
Joining the program is easy and you can apply at any time of the year. Just complete the application and mail or fax it to EPIC. EPIC verifies information with the Social Security Administration and the New York State Department of Taxation and Finance.
* You must be a New York State resident 65 years of age or older and be enrolled or eligible to be enrolled in a Medicare Part D drug plan to receive EPIC benefits and maintain coverage. EPIC provides secondary coverage for Medicare Part D- and EPIC-covered drugs after any Part D deductible is met. EPIC also covers approved Part D-excluded drugs such prescription vitamins as well as prescription cough and cold preparations once a member is enrolled in a Part D drug plan. Learn more at the New York State Department of Health website.
Do you believe you have qualified for extra help and that you are paying an incorrect copayment amount?
If you believe you are paying an incorrect copayment amount when you get your prescription at the pharmacy, we can help you confirm your eligibility. We follow Medicare's Best Available Evidence Policy and if you have the appropriate documentation, we can help you sort out your eligibility issues. Call Customer Service toll-free at 1-877-883-9577 (TTY/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Feb. 14, representatives also are available weekends from 8 a.m. to 8 p.m.
What is Best Available Evidence?
Medicare's Best Available Evidence Policy is used to determine eligibility for extra help with prescription drug costs when information is not readily available to us through other standard sources. This policy allows a member, member's pharmacist, advocate, representative, family member or other individual acting on behalf of the member to submit certain documentation that we will use to update a member's eligibility when appropriate
Examples of Acceptable Documentation
If You are Dual Eligible
For additional assistance on where to send your documents, please call Customer Service toll-free at 1-877-883-9577 (TTY/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Feb. 14, representatives also are available weekends from 8 a.m. to 8 p.m.
Follow this link to View Medicare's Best Available Evidence Policy. You will be taken to the Centers for Medicare and Medicaid Services (CMS) Website.
As a new member in our Plan you may be taking drugs that aren't on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. You should talk to your doctor to decide if you should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See Section 5 of the Evidence of Coverage under "What is an exception?" to learn more about how to request an exception. Please contact our Pharmacy Help Desk if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or to request a formulary exception.
During the period of time you are talking to your doctor to determine the right course of action, we may provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year.
When you go to a network pharmacy and we provide a temporary supply of a drug that isn't on our formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.
If you are a new member and a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days you are a new member enrolled in our Plan. If you are a long-term care facility resident and have been enrolled in our Plan for more than 90 days and need a drug that isn't on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while you pursue a formulary exception.
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 purchased at an out-of-network pharmacy, unless you qualify for out-of-network access. See Section 10 of the Evidence of Coverage for information about non-Part D drugs.