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-POS℠ Comprehensive 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 HMO-POS℠ 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 HMO-POS℠ 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 contract 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

Prior Authorization Information and Criteria (PDF)
Step Therapy Information and Criteria (PDF)
Quantity Limits (PDF)

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.
Medco Medicare Part D Coordination of Benefits and Direct Claim Form (PDF)
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.

Extra help with your monthly plan premium

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to one hundred (100) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. 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 even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.

Forms for physicians

Use the Medicare Part D Coverage Determination Request Form (PDF) to request coverage for a BCN Advantage HMO-POS member.
Physicians should use the Walgreens physician fax order form (PDF) to order prescription drugs for BCN Advantage members.
Use the Medco Mail Order form, which is available by calling Medco at 1-800-229-0832 (TTY 1-800-759-1089), 24 hours a day, seven days a week (except Thanksgiving and Christmas), or visit the Medco website.

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-POS℠
BCN Advantage HMO-POS 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 have both Part A and B and continue to pay your Medicare Part B premium.

You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor BCN Advantage HMO-POS will be responsible for the costs, and your care may cost more than in-network pricing. Limitations, copayments and restrictions may apply.

If you are enrolled in BCN Advantage HMO-POS Basic, 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. Quantity limitations and restrictions may apply. 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 Services at 1-800-450-3680, 8 a.m. to 8 p.m., seven days a week. TTY users should call 1-800-430-3211. You may also write to: BCN Advantage HMO-POS, P.O. Box 5184, Mail Code A103, Southfield, MI 48086-5184

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1, 2012.

If you decide to have your BCN Advantage HMO-POS 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.

Medicare beneficiaries may enroll in BCN Advantage HMO-POS through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. Beneficiaries may only enroll during specific times of the year. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
Your State Medicaid Office.

A health plan with a Medicare contract.

H5883_BCNAdvantageWebR2 CMS Approved 05242011

page modified 09/23/2011