Blue Medicare Advantage pharmacy information

Blue Medicare Advantage Drug Formulary

The list of drugs covered on each plan, along with any restrictions for those drugs, can be found in the formulary guides below.

• 2023 Drug Formulary
• 2023 Prescription Drug Formulary Online Search

Blue Medicare Advantage Drug Pricing Tools

• 2023 Blue KC Essential (PPO)
• 2023 Blue KC Secure (HMO)
• 2023 Blue KC Simply Blue (PPO)
• 2023 Blue KC Giveback (PPO)
• 2023 Blue KC Spira Care (HMO)

Utilization management

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed the following requirements and limits for our plans to help us provide quality coverage to our members:

• Prior authorization: We require you to get prior authorization for certain drugs. This means that your doctor will need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug.
  2023 View Blue Medicare Advantage Prior Authorization Criteria
• Step therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
  2023 View Blue Medicare Advantage Step Therapy Criteria
  Blue Medicare Advantage Part B Therapy Drug List
• Quantity limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time.
• Generic substitution: When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug.

You can find out if the drug you take is subject to these additional requirements or limits by looking in the drug formulary. If your drug is subject to one of these additional restrictions or limits, and your physician determines that you are not able to meet the additional restriction or limit for medical necessity reasons, you or your physician can request an exception (which is a type of coverage determination).

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 prescribes 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:

• Possible medication errors
• Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
• Drugs that are not safe or appropriate because of your age or gender
• Possible harmful interactions between drugs you are taking at the same time
• Drug allergies
• Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

You may be able to get a temporary supply

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

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:
   • The drug you have been taking is no longer on the plan’s drug list.
   • The drug you have been taking is now restricted in some way.
2. You must be in one of the situations described below: For those 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 108 days of your membership in the plan if you were new and during the first 108 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.

For those 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 108 days of your membership in the plan if you are new and during the first 108 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 31-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)

For those members who have been in the plan for more than 108 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.

View the Blue Medicare Advantage Transition Policy

Pain medicines can be an important part of care, but opioid pain medicines, such as hydrocodone, oxycodone, or morphine, require close monitoring by a healthcare provider to ensure that they are being used safely. Here are some tips to help you use these medicines in a safe manner.

• It is best to have only one doctor prescribe opioid pain medicines for you, and to use only one pharmacy. This helps make sure the right type and amount of medicine is prescribed for you, and that unsafe amounts or combinations can be detected by the pharmacy.
• Tell all your doctors what pain medicines you are taking and who is prescribing them.
• Take your pain medicines as prescribed. Do not take extra doses without direction from your healthcare provider. This could be dangerous or cause you to run out of medicine before it can be refilled.
• Don’t take opioid medicines from someone else or share yours with others. Each person’s body becomes used to their prescribed medicine and dose, and taking a different type or amount could be dangerous.
• Keep your opioid medicine in a safe and secure place, out of reach of family, children, and visitors. Keep them in the original container.

Blue Medicare Advantage already promotes the safe use of opioid medicines by limiting the amount of each opioid that you can get at one time (formulary quantity limits). We do an additional safety review when one or more of your opioid prescriptions exceed a certain high amount of opioids. The Blue Medicare Advantage system will calculate the amount of all opioids you are currently filling. If the combined amounts go above a certain threshold and you have opioid prescriptions from two or more healthcare providers, the prescription cannot be filled at the pharmacy. This will help you avoid taking unsafe amounts if multiple healthcare providers have prescribed opioids for you without communicating with each other, or if you are filling opioid prescriptions at more than one pharmacy.

If your doctor feels that you need higher amounts of opioid medicines than what the system will allow, he or she can ask us to cover more by submitting a coverage determination request.

If you are in hospice care, in a Long-Term Care Facility, filling a prescription for cancer medicine or filling a prescription for sickle cell disease medicine, your opioid prescriptions will not be affected.

We offer a free program to help our members with their medicines. It is called the Medication Therapy Management Program. Some members who take several medicines for different medical conditions may qualify for the program.

Better therapeutic outcomes for members with multiple conditions

Our Medication Therapy Management Program (MTMP) is focused on improving therapeutic outcomes for Medicare Part D members. To qualify for MTMP, a member must meet all the following criteria:

• Members must have filled eight or more chronic Part D medications
• Members must have at least three of the following ten chronic conditions
  • High Blood Pressure
  • High Cholesterol
  • Congestive Heart Failure (CHF)
  • Diabetes
  • Depression
  • Osteoporosis
  • Rheumatoid Arthritis
  • Asthma
  • COPD
  • HIV
• Members must be likely to incur annual costs of $4,935 for all covered chronic Part D medications.

OR

• Are in a Drug Management Program to help better manage and safely use medications such as opioids and benzodiazepines.

Do you meet all of the criteria above? Learn more about how to manage the various medications you need to stay healthy.

The success of our MTMP is built upon our proven experience using a wide range of services designed to help members with multiple conditions by:

• Ensuring they take their medications correctly
• Improving medication adherence
• Detecting potentially harmful medication uses or combinations of medications
• Educating members and health care providers

Our programs are evidence-based and can integrate both pharmacy and medical data, when available, and are built upon multiple measures that demonstrate positive clinical outcomes for members like you. Pharmacists, physicians and PhDs develop, manage and evaluate the programs for effectiveness.

One-on-one consultations between our clinicians and members are also an important part of our MTMP. Such consultations ensure that members are taking their medications as prescribed by their health care provider.

Comprehensive Medication Review (CMR)

The Centers for Medicare & Medicaid Services (CMS) requires all Part D sponsors to offer an interactive, person-to-person comprehensive medication review (CMR) to all MTM-eligible members as part of MTMP. If you meet the criteria outlined above, you will receive an MTMP Enrollment Mailer or phone call offering our CMR services. A CMR is a review of a member’s medications (including prescription, over-the-counter (OTC), herbal therapies and dietary supplements), which is intended to aid in assessing medication therapy as well as optimizing outcomes. Also, MTMP-eligible members will be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which members’ prescribers may receive a member-specific report.

The CMR includes three components:

1. Review of medications to assess medication use and identify medication-related problems. This may be conducted person-to-person or “behind the scenes” by a qualified provider and/or using computerized, clinical algorithms.
2. An interactive, person-to-person consultation performed by a qualified provider at least annually to all MTM-eligible members.
3. An individualized, written summary of the consultation for the member, including but not limited to, a medication list, reconciled medication list, and recommended to-do list for monitoring, education, or self-management.

View a copy of the recommended to-do list

View a copy of the medication list

Safely dispose of unused or expired medication

Do you have unused expired medications and are looking for a safe way to dispose of them? For safety reasons, dispose of unused medications as soon as possible. Here is how to safely dispose of unused or expired medications before they do harm:

• Find a nearby pharmacy or other local resource with a medication take back service.
  • The US Drug Enforcement Administration (DEA) allows unused prescription medications to be returned to pharmacies or other authorized sites. You can locate participating locations here.
  • Community take back sites are the preferred method of disposing of unused controlled substances.
  • Additional drug disposal information can be found on the DEA website.
• If you cannot get to a drug take back location promptly, or there is none near you:
  • Mix the unused supply with an undesirable substance such as dirt or coffee grounds.
  • Put the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag, then place the sealed container in your trash.
  • Make sure to conceal or remove any personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off to protect your privacy.
  • Place both the sealed container with the mixture and the empty drug containers in the trash.
  • Only flush approved unused or expired medications down the toilet only if indicated on the label, patient information, or no other disposal options are available.

More information on the safe disposal of medications can be found on the United States Department of Health and Human Services website.

Contact your health plan at the number listed on the back of your ID card for more information about our MTMP. If you have any questions about the MTM program, please call the MTM Department at 1-844-583-9549. (TTY users dial 711), Monday-Friday, 8 a.m. to 8 p.m. CST.

These programs are provided at no additional cost as part of your coverage and are not considered a benefit.