Blue Care Network of Michigan: Drug formulary

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Drug formulary

For more information call:
1-877-469-2583
TTY 1-800-481-8704
Seven days a week
8 a.m. to 8 p.m. Eastern Time

The BCN Advantage HMO Formulary is a list of FDA-approved medications that have been reviewed by a team of Michigan pharmacists, physicians and other health care experts. The team selects covered drugs based on their clinical effectiveness, safety and cost savings. BCN will generally cover drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BCN Advantage network pharmacy and other plan rules are followed. For more information on your prescription drug coverage, please see our frequently asked questions or review your Evidence of Coverage.

Individual coverage—lists of covered drugs

Comprehensive Formulary

BCN Advantage Comprehensive Formulary (PDF)

Formulary Updates

The Formulary Updates document below lists drugs that have been added to, removed from or updated in our formulary.

BCN Advantage Comprehensive Formulary Updates (PDF)

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 contract year 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.

Prior Authorization, Step Therapy and Quantity Limit Restrictions

Forms for members

Use the Member Request for Medicare Drug Coverage Determination Form (PDF) if you are requesting coverage before paying for a drug.
Use the Member Claim/Reimbursement Form (PDF) if you are seeking reimbursement for a drug claim you have already paid.
Use the Walgreens mail order form (PDF) to order prescription drugs from Walgreens Mail Service Pharmacy.

Forms from Medicare for members

Use the Member Request for Medicare Drug Coverage Determination Form (PDF) if you are requesting coverage before paying for a drug.

Forms for physicians

Use the Medicare Part D Coverage Determination Request Form (PDF) to request coverage for a BCN Advantage HMO member.
Physicians should use the Walgreens physician fax order form (PDF) to order prescription drugs for BCN Advantage members.

Forms for physicians from Medicare

Use the Medicare Part D Coverage Determination Request Form (PDF) to request coverage for a BCN Advantage member.

Group Coverage—Prescription Drug Coverage

Prescription drug coverage for members of an employer group

Important information about this plan

BCN Advantage HMO is available in these counties: Allegan, Barry, Bay, Calhoun, Clinton, Eaton, Genesee, Gratiot, Ingham, Ionia, Jackson, Kalamazoo, Kent, Lapeer, Livingston, Macomb, Midland, Monroe, Montcalm, Muskegon, Newaygo, Oakland, Oceana, Ottawa, Saginaw, Shiawassee, St. Clair, Tuscola, Van Buren, Washtenaw and Wayne. Premiums vary by county. You must continue to pay your Medicare Part B premium.

You must use plan providers except in emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor BCN Advantage HMO will be responsible for the costs. Out-of-network services authorized by BCN Advantage HMO will be covered.

If you are enrolled in BCN Advantage HMO Option 2 or Option 3, you must use a network pharmacy to access your prescription drug benefit, except under non-routine circumstances when you cannot reasonably use a network pharmacy. Our pharmacy network includes the majority of chain pharmacies, mail order through Medco or Walgreens, as well as long-term care and home infusion pharmacies. For additional information on network pharmacies, please call Customer Service at 800-450-3680, 8 a.m. to 8 p.m., seven days a week. TTY users should call 800-430-3211. You may also write to: BCN Advantage HMO, 2311 Green Road, Ann Arbor, MI 48105.

The BCN Advantage HMO benefit information provided is not comprehensive. Additional information should be requested before making a decision about your coverage. For full information on BCN Advantage HMO benefits, current members should call our Customer Service department at 800-450-3680, from 8 a.m. to 8 p.m., seven days a week. TTY users should call 800-430-3211. Prospective members should call 877-469-2583, from 8 a.m. to 8 p.m., seven days a week. TTY users should call 800-481-8704.

Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1, 2011. Please contact BCN Advantage HMO for details.

If you decide to have your BCN Advantage HMO 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.

BCN Advantage HMO is issued by Blue Care Network, which contracts with the federal government. BCN Advantage HMO’s contract with CMS is renewed annually and the availability of coverage beyond the end of the contract year is not guaranteed.

BCN Advantage HMO^SM is a health plan with a Medicare contract.

H5883_BCNAdvantageWebR4 CMS Approved 07012010

page modified 05/19/2010