Prescription Drug Information

Our Medicare Advantage plans are offered with or without a prescription drug benefit.  Click on the Medicare Formulary to see which drugs are covered by the plan. 

Click on the Notice of Formulary Change box to see a summary of the month to month formulary changes including additions and deletions.

Click on the Extra Help From Medicare box to find out if you may qualify for extra help to pay for your prescription drug costs.

The New York State EPIC Program box has a link directly to the NYS Website where you can learn if you qualify for additional help lowering your prescription drug costs.


The 2017 Medicare Formulary includes a list of prescription care drugs covered by a prescription drug plan.

View 2017 Medicare Advantage Formulary

The Medicare Advantage Formulary has been updated since its original printing in August, 2016. The document below outlines all of the updates to the Formulary as of September 1, 2017.

View 2017 Medicare Advantage Formulary Update

With over 63,000 pharmacies serving our members locally and nationally, our pharmacy network meets the pharmacy access requirements as mandated by the Centers for Medicare and Medicaid Services (CMS).

Find a Pharmacy

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30 day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30 day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with at least a 91 day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31 day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

If a member submits a prescription for a transition eligible drug and it is rejected at Point of Sale, a message will be relayed to the pharmacist to call for additional instructions if the member underwent a recent level of care change. After confirming the member had a level of care change, the pharmacist will be instructed to enter a series of override codes to allow the member to receive a one-time transition supply of his or her prescription. At that time, all transition supply procedures will apply including member notifications for transition supply fills.

We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are two instances when we would cover prescriptions filled at an out-of-network pharmacy:

  • There are no network pharmacies within a reasonable driving distance that provide 24 hour service.
  • You need to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).

In situations like these, please check first with Pharmacy Services to see if there is a network pharmacy nearby.

Our numbers are:
800-294-8216 - Senior Blue HMO Plan
800-295-7913 - Forever Blue Medicare PPO Plan
TTY/TDD: 711

Quantity Limit amounts and days for prescriptions for Medicare Members.

View 2017 Medicare Formulary

Instructions for when we require you to try certain drugs to treat a medical condition before we will cover another drug for that condition.

View Guidelines

Services or programs that optimize therapeutic outcomes for individuals through improved medication use. These programs are not considered a benefit.  Please contact customer service for additional information. 

View Details

You might qualify to get help in paying for your drugs. “Extra Help” from Medicare, also called the “low-income subsidy” or LIS.

Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs:

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.

This table shows you what your monthly plan premium will be if you get extra help.
 

Your level of extra help
Monthly Premium for Senior Blue Select*
Monthly Premium for Senior Blue HMO 651*
Monthly Premium for Forever Blue Medicare PPO 751*
Monthly Premium for Forever Blue Medicare PPO Value*
Monthly Premium for Forever Blue Medicare PPO Focus*

100%

$0.00

$67.00

$157.00

$70.00

$37.00

75%

$10.30

$77.30

$167.30

$80.30

$47.30

50%

$20.50

$87.50

$177.50

$90.50

$57.50

25%

$30.80

$97.80

$187.80

$100.80

$67.80

 

*This does not include any Medicare Part B premium you may have to pay.

The BlueCross BlueShield of Western New York Medicare Advantage plan premiums listed above include coverage for both medical services and prescription drug coverage.

Refer to your Evidence Coverage – LIS Rider for detailed information, including your exact premium amount and prescription drug co-pays. If you get your coverage through your former employer, please contact the benefits administrator for your premium amount.

If you aren't getting extra help, you can see if you qualify by calling:

1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours per day, 7 days per week.

Your State Medicaid Office, or

The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

EPIC (Elderly Pharmaceutical Insurance Coverage) is a program offered by New York State that helps seniors pay for prescription drugs. EPIC can help lower Part D drug costs by helping pay for drugs in the coverage gap, as well as providing assistance with Part D premiums, if eligible.

Learn more about EPIC

Review this information if you believe you may qualify for 'extra help' with your Medicare Prescription Drug Plan costs, but your plan's system and CMS's systems do not reflect your eligibility for this help. Find out how you may be able to obtain your prescriptions at the correct Low Income Subsidy (LIS) cost sharing level if you can show evidence of your LIS eligibility.

Learn More

If BlueCross BlueShield denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.

Submit Request Online     Download Paper Form

A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage Plan. 

Submit Request Online      Download Paper Form



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This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B Premium.

Out-of-network/non-contracted providers are under no obligation to treat BlueCross BlueShield of Western New York members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

BlueCross BlueShield of Western New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal.

Y0086_MRK1717 Approved
Content Last Updated December 15, 2016