Every Blue Advantage (HMO) | Blue Advantage (PPO) plan includes generous Part D prescription drug coverage to help with the costs of your medications. Information about what medications are covered can be found in the drug formulary and the Evidence of Coverage.
It is important to remember that enrollment in Blue Advantage does not affect Medicare coverage for any drugs that may be covered under Medicare Part A or Part B. If you meet Medicare’s coverage requirements, your drugs will still be covered under Medicare Part A or Part B even though you are enrolled in Blue Advantage. See the Medicare & You Handbook for more information about the drugs that are covered by Medicare Part A and Part B.
Important Note: Blue Advantage members automatically receive their Medicare Part D prescription drug coverage. If you join another Medicare plan, including a Medicare prescription drug plan, you will be disenrolled from our plan when your enrollment in the new plan begins.
Blue Advantage (HMO) | Blue Advantage (PPO) members are automatically enrolled in Medicare Part D drug coverage. A formulary is a list of covered drugs selected by Blue Advantage in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program.
Blue Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue Advantage network pharmacy, and other plan rules are followed.
Find and Price Prescription DrugsDownload a Print Version of the Formulary
If you would like to download a print version our 2021 Prescription Drug Formulary, click the link below.
2021 Blue Advantage Prescription Drug FormularyOur drug formulary may change during the year. These changes will be updated regularly. You can view any changes that have been made to the 2021 prescription drug formulary by clicking the link below.
2021 Blue Advantage Prescription Drug Formulary Change NoticeGeneric Drugs
A generic drug has the same active ingredient as the brand-name version of the 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. If your brand-name drug is not listed in our formulary, it may be listed in its generic form. Check with your doctor or pharmacy to see if a generic is available.
Diabetic Testing Supplies
Blue Advantage (HMO) | Blue Advantage (PPO) offers members several choices of glucose meters and test strips. We cover Abbott and LifeScan meters and test strips through network pharmacies.
Click here for coupons to use at a Blue Advantage network pharmacy to get a FREE meter.
Certain covered drugs may have requirements or limits on coverage. Our staff works with a team of outside healthcare providers to help determine these requirements. They are designed to ensure that prescription drugs are used in a safe and effective way while helping to control drug plan costs. You can find out if your drug has any of these requirements or limits on coverage by looking in the formulary. These requirements or limits may include:
Prior Authorization
We require you to get prior authorization for certain drugs. This means that your doctor will need to get approval from the plan before you fill your prescription. If they don’t get approval, we may not cover the drug. Click on the link below to view the prior authorization criteria used by the plan to determine if the drug is covered.
Learn more about Prior Authorization Criteria
Step Therapy
We may require that you try one or more alternative drugs for your health condition before we will cover the drug you are requesting. If you have already tried other drugs or your doctor thinks other drugs are not right for your situation, you or your doctor can ask the plan to cover the requested drug. Click on the link below to view the step therapy criteria used by the plan.
Learn more about Step Therapy Criteria
Quantity Limits
For certain drugs, Blue Advantage limits the amount of the drug that the plan will cover per prescription or for a defined period of time. For example, Blue Advantage provides 18 tablets per 28 day prescription for sumatriptan.
Generic Substitution
In most cases, when there is a generic version of a brand-name drug available, our network pharmacies will give you the generic version. We usually will not cover the brand name drug when a generic version is available. However, if your provider has told us the medical reason that neither the generic drug nor other covered drugs that treat the same condition will work for you, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.)
Drug Utilization Review
We conduct drug utilization reviews for all of our members to make sure that they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:
If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
Under certain circumstances, you may be able to get a temporary supply of a drug when your drug is not on the Drug List or when it is restricted in some way. This gives you time to talk with your provider about your options.
To be eligible for a temporary supply, you must meet the two requirements below:
1. The change to your drug coverage must be ONE of the following types of changes:
2. You must be in ONE of the situations described below:
Members who are new or who were in the plan last year and aren’t in a long-term care (LTC) facility:
We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy.
Members who are new or who were in the plan last year and reside in a long-term care (LTC) facility:
We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are new and during the first 90 days of the calendar year if you were in the plan last year. The total supply will be for a maximum of a 98-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 98-day supply of medication. The long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.
Members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away:
We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
To learn more, read our Transition Policy.
We are committed to improving the health and lives of our members. Learn more about how to safely use opioid pain medications and what features we use to protect you when filling your prescriptions.
For your convenience, the Blue Advantage (HMO) | Blue Advantage (PPO) pharmacy network includes more than 60,000 pharmacies nationwide, including more than 1,200 in Louisiana. You may go to any of our network pharmacies to receive your covered prescription drugs.
The Blue Advantage pharmacy network includes pharmacies that offer preferred cost-sharing and pharmacies that offer standard cost-sharing. When you use a preferred retail pharmacy or the Express Scripts mail-order pharmacy, you will pay less for drugs on Tiers 1 through 3 than you would if you use a standard retail or mail-order pharmacy. Learn more about our Preferred Pharmacy Network.
For more information about Express Scripts mail-order pharmacy, visit the Save Time and Money Filling Covered Drugs page.
Use our online provider search tool to locate a participating pharmacy near you.
Blue Advantage offers a nationwide pharmacy network, but our directory list only contains pharmacies located within Louisiana. For help locating a network pharmacy in another state (including those that offer preferred cost-sharing), please contact Customer Service.
Out-of-Network Pharmacies
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Examples of circumstances when we would cover prescriptions filled at an out-of-network pharmacy include:
Your prescription cost may be more at an out-of-network pharmacy than at an in-network pharmacy. For more information, see your Evidence of Coverage.
Special note: Some Blue Advantage – Medicare Advantage for Employer plans do not offer preferred cost-sharing when you use a preferred pharmacy. You can still use a preferred pharmacy but may not pay less for your prescriptions than you would at a standard network pharmacy. If you are a Blue Advantage – Medicare Advantage for Employer member, read your plan’s Benefit Documents to see if this applies to you.
As a Blue Advantage (HMO) | Blue Advantage (PPO) member, you can use these money and time-saving tools to make getting your medicine easier! You can use these tools to fill certain drugs you may take for a long time to treat health problems such as high blood pressure, diabetes or high cholesterol.
Preferred Pharmacy Network
The Blue Advantage pharmacy network includes a group of participating pharmacies that offer preferred cost-sharing for your Medicare Part D prescriptions. You may pay less for your medication when you choose a preferred pharmacy to fill your prescription!
Mail-Order Pharmacy
When you use Express Scripts PharmacySM, your prescription can be mailed directly to your door. Plus, you pay nothing for standard shipping. Express Scripts PharmacySM is the preferred mail-order pharmacy in your network, so you will pay less for drugs on Tiers 1 through 3.
90-day Supply
You can get 90 days’ worth of most drugs. This is called a long-term supply or extended supply. If you expect to take your drug for at least 3 months, this is an easy way to make sure you have your drug on hand. Plus, if you use a preferred retail pharmacy or Express Scripts PharmacySM, you will pay $0 for a 90-day supply of Tier 1 drugs.
For copay and coinsurance information, see Paying for Prescription Drugs. Or check your plan’s Formulary or Benefit Documents.
Special note: Some Blue Advantage – Medicare Advantage for Employer plans do not offer preferred cost-sharing when you use a preferred pharmacy. You can still use a preferred pharmacy but may not pay less for your prescriptions than you would at a non-preferred network pharmacy. If you are a Blue Advantage – Medicare Advantage for Employer member, read your plan’s Benefit Documents to see if this applies to you.
At Blue Advantage (HMO) | Blue Advantage (PPO), we know that taking your prescription drugs as your doctor orders can mean better health outcomes for you. That’s why we offer you support to help you stay on track and stay healthy.
Medication Refill Reminders
We may call to check on you when certain medications are refilled late or if you have been late refilling medications in the past. You can also speak with a pharmacist who can help you overcome any barriers keeping you from getting and taking your medicine. The pharmacist can offer helpful tips, provide you with reminder tools or help transfer your prescriptions to mail order.
Medication Therapy Management (MTM) Program
The Medication Therapy Management (MTM) Program is a service for members with multiple health conditions who also take multiple medicines. The MTM program helps you and your doctor make sure that your medicines are working to improve your health.
To qualify for the MTM program, you must be eligible. Please see below for those details. If you qualify, you will be auto-enrolled into the program and the service is provided at no additional cost to you. You may choose not to participate in the program, but it is recommended that you make use of this free service
You may qualify for the MTM Program if:
1. You have 3 or more chronic health problems. These may include:
2. You take 8 or more chronic/maintenance medicines covered by Medicare Part D.
3. You spent $1,094 in the previous 3 months on Part D covered medications.
If you qualify, you will receive a letter with information on scheduling a 20 – 30 minute phone call for a detailed medication review. During that call, a pharmacist or pharmacy intern will complete a comprehensive medication review of your medicines and talk with you about:
A summary will be mailed to you that includes a medication action plan with space for you to take notes or write down any follow-up questions. You will also receive a personal medication list of all the medicines you take and why you take them. At least once every 3 months, your medications will be reviewed, and you or your doctor will be contacted about any possible changes in your medicines.
The MTM Program is offered through our partnership with Express Scripts Inc. and Sinfonia Rx. and is not considered a part of the plan’s benefit.
The Explanation of Benefits (EOB) is a document you will get each month if:
Your Explanation of Benefits includes:
Please Note: Items/services appear on the EOB when a claim is processed, not necessarily for the month in which you received the item or service.
To get your EOBs online, register at www.express-scripts.com. You will need your member ID number to register. Under My Account, go to Select Communication Preferences, click Communication Preferences, then Edit Preferences, and then choose to get your printed materials online. You’ll receive your Medicare Part D EOB statements online rather than by mail. There’s no cost, and you can switch back to paper EOBs anytime.
By registering, you can also:
If you have a question about any information contained in your EOB, we encourage you to contact us.
Low Income Subsidy Premiums for Blue Advantage Plan Year
Medicare provides Part D premium and cost-sharing assistance to beneficiaries who qualify for the program's low income subsidy, also called the LIS. An enrollee’s premium will generally be lower once they receive "Extra Help" from Medicare, if the enrollee joins a Blue Advantage plan with a monthly premium.
If you qualify for "Extra Help," you pay $0 or a reduced monthly premium.
Learn more about what information is needed to have your records immediately updated to reflect that you qualify for "Extra Help" (low income subsidy).
Part D sponsors must provide access to Part D drugs at the correct LIS cost-sharing level when presented with evidence of LIS eligibility
Learn more about CMS' "Best Available Evidence" (BAE) policy.
People with limited incomes may qualify for "Extra Help" to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, copays and/or coinsurance. 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.
To find out more about Medicaid and its programs, contact:
Louisiana Department of Health
P.O. Box 629
Baton Rouge, LA. 70821-0629
Phone: 1-888-342-6207
www.medicaid.la.gov
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