General Transition Notice

For Capital Blue Cross Medicare HMO and PPO Members

What if my current prescription drugs are not on the formulary or are limited on the formulary?

New Members

As a new member of our Plan, you may currently be taking drugs that are not on our formulary or are on our formulary but your ability to get them is limited. We encourage you to talk with your doctor about appropriate alternative therapies that are included on our formulary. If there are no appropriate alternative therapies included on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you may be eligible to receive a temporary supply of the drug anytime during the first 90 days you are a member of our Plan.

For each of your drugs that is not on our formulary or for situations where 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 retail pharmacy or the Plan’s designated mail order pharmacy. After you receive your 30-day temporary supply, the drug may no longer be eligible for coverage under our transition policy.

If you are a resident of a long-term care facility, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days). We will cover more than one fill of these drugs for the first 90 days you are a member of our Plan. If 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.

Continuing Members

You will receive your Annual Notice Of Change (ANOC) by September 30. You may notice that a medication that is on our current formulary is either not on the upcoming year’s formulary or coverage is limited in the upcoming year.

You may be eligible for a temporary 30-day supply of your medication during the first 90 days of the plan year when you go to a network retail pharmacy or the Plan’s designated mail order pharmacy. Residents of long-term care facilities may be eligible to receive a 31-day temporary supply, during the first 90 days of the plan year.

We encourage you to work with your doctor to find an appropriate alternative therapy on our new formulary or request a formulary exception prior to the beginning of the new year. If the exception request is approved, we will authorize payment prior to January 1 and provide coverage beginning January 1.

If you need assistance with requesting an exception or for more information about our transition policy, please call Member Services, at 1.866.987.4213 or Capital Blue Cross Medicare PPO or 1.800.779.6962 for Capital Blue Cross Medicare HMO TTY 711), 24 hours a day, 7 days a week.

View General Transition Policy.