Request forms can also be faxed to: 800-464-5942.
Medicare Advantage Prescription Drug (MAPD ) Plan - Prescription Drug Information - Conditions, Limitations, Out of Network Drug Coverage:
- Conditions and Limitations (Empire BlueCross): By law, certain types of drugs or categories of drugs are not covered by Medicare Prescription Drug Plan sponsors. These drugs or categories of drugs are called "exclusions". Please note that excluded drugs cannot be requested as an exception.
- Conditions and Limitations: (Empire BlueCross BlueShield) By law, certain types of drugs or categories of drugs are not covered by Medicare Prescription Drug Plan sponsors. These drugs or categories of drugs are called "exclusions". Please note that excluded drugs cannot be requested as an exception.
- Out of Network Prescription Drug Coverage (Empire BlueCross): Review the procedures for filling prescriptions outside of the network
- Out of Network Prescription Drug Coverage (Empire BlueCross BlueShield): Review the procedures for filling prescriptions outside of the network
Process for Exceptions to the List of Covered Drugs (formulary):
Here are examples of coverage decisions you ask us to make about your Part D drugs:
You ask us to make an exception, including:
- Asking us to cover a Part D drug that is not on the plan's List of Covered Drugs (Formulary)
- Asking us to waive a restriction on the plan's coverage for a drug (such as limits on the amount of the drugs you can get)
- Asking to pay a lower cost-sharing amount for a nonpreferred drug
Review the Prescription Drug Transition Policy
How do I request an exception to the formulary?
To submit a request for a coverage determination, utilization exception, formulary exception, or tiering exception:
Important Information about premiums:
If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months for it take effect and you will ultimately be held responsible for those premiums.
You may be able to get extra help to pay for your prescripton drug premiums and costs.
For more information about receiving extra help to pay for your prescription drug coverage, select a plan and review the LIS (Low Income Subsidy) Premium Summary Chart.
To see if you qualify for getting extra help, you may also call:
- 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7days a week), or
- The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call, 1-800-325-0778, or
- Your State Medicaid Office.
*In certain cases, CMS systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. In order to address these special situations, CMS has created the Best Available Evidence (BAE) policy. This policy requires Part D plans to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate. For more information about this CMS policy, click here
If you have qualified for additional assistance for your Medicare Prescription Drug Plan costs, the amount of your premium
and cost at the pharmacy will be less. Once you have enrolled in a (PDP) plan, Medicare will tell us how much assistance you are receiving, and we will send you information on the amount you will pay. If you are not receiving this additional assistance, you should contact 1-800-MEDICARE (TTY/TTD users call 877-486-2048), your state Medicaid Office, or local Social Security Administration Office to see if you might qualify.
Our prescription drug plan (PDPs) and Medicare Advantage prescription drug (MAPD) plans have a Medicare contract. Since contracts with Medicare are renewed annually, both the Prescription Drug Plans and the Medicare Advantage prescription drug (MAPD) plans cannot guarantee availability of coverage beyond the end of their current contract year.
If our Medicare contract is terminated or if we stop offering PDP or MAPD benefits, we will give you written notice of when that change will be effective. We will also provide you with information about alternative Prescription Drug Plans or Medicare Advantage prescription drug (MAPD) plans in your area, and the steps you need to take to continue your prescription drug coverage with Medicare. At that time, you would be eligible for a Special Enrollment Period, and could choose a new PDP sponsor or MAPD sponsor without being subject to a late enrollment penalty.
Contract Termination Procedures
All Medicare Prescription Drug Plans and Medicare Advantage prescription drug (MAPD) plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Prescription Drug Plan or Medicare Advantage prescription drug (MAPD) plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 60 days before your coverage will end. The letter will explain your options for Medicare prescription drug coverage in your area.
Materials may be available in alternative formats.