If you have a medically necessary need for a non-formulary drug, you can ask us to make an exception and cover the drug. We respond to exception requests within 72 hours. There are three types of exceptions that you can ask for.

• Coverage for a drug, even if it is not on our drug list
• Waiving coverage restrictions or limits on a drug
• Lowering the tier cost of a drug

If we deny your exception request, we will mail you a letter explaining why your request was denied. This letter will include how you can appeal our decision. You can ask for a standard or expedited appeal.

New members have a 90-day transition period after they enroll in our plan. During this time, you can get a one month supply of your prescriptions that are not on our drug list, or that have step therapy or prior authorization requirements. After you get your month's supply, it is a good time to talk with your provider about a formulary exception or other drugs that may work for you.

If Customer Service confirms that we do not cover your drug, you can do the following:

• Ask your provider if you can switch to another drug that the plan covers. Call Customer Service if you need a list of covered drugs to share with your provider.
• Ask us to make an exception and cover your drug by completing our form:
  • Request for Medicare prescription drug coverage determination form
  • Solicitud de Determinacion de Cobertura de Medicamentos Recetados de Medicare
• Using the Prescription Drug Coverage Determination form, you can also ask for an Expedited Exception (Expedited Decision). If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.
• Return this form by mail to Blue Cross of Idaho Rx, P.O. Box 47686, San Antonio, TX 78265, or by fax at 1-844-521-6938.

You can also purchase your drug and ask for reimbursement by making an exception request.

Return the redetermination form by mail or fax as shown on the form.

If you have a medically necessary need for a non-formulary drug, you can ask us to make an exception and cover the drug. If we deny your exception request, we will mail you a letter explaining why your request was denied. This letter will include how you can appeal our decision. You can ask for a standard or expedited appeal.

• For standard appeals, we must provide a decision no later than seven days after we get your appeal request.
• Ask for an expedited (fast) appeal when you or your doctor believes that your health could be seriously harmed by waiting up to seven days for a decision. We will give you a decision no later than 72 hours after we get you expedited appeal request.

If your prescribing doctor supports your expedited appeal or requests an expedited appeal for you, we automatically grant you a faster decision. If you request an expedited appeal without support from a doctor, we determine whether or not your health situation requires a fast appeal. In the event we determine your situation does not require a fast decision, we give you a decision within 7 days. We will not expedite an appeal for a drug you already receive.

Request an appeal

• Expedited Appeals: You or your appointed representative should contact us by telephone at 1-855-479-3661, or fax at 1-844-430-6802
• Standard Appeals: You or your appointed representative should complete the proper form:
  • Request for Redetermination of Medicare Prescription Drug Denial
  • Solicitud de redeterminación de rechazo de medicamento recetado de Medicare
  and mail it to Blue Cross of Idaho Rx, PO Box 775370, St. Louis, MO 63177. You may also fax it to 1-844-430-6802

Next Steps

We will review your appeal and give you a decision. If we deny your appeal, you can request an outside review by an independent reviewer not associated with our plan.

If you disagree with that decision, you still have the right to appeal further. We will notify you of your appeal rights if this happens.

Our contact information

If you need help with an appeal, call Customer Service at 1-855-479-3661 or TTY 711, 24 hours a day, seven days a week.

Other Resources

• Medicare Rights Center, 1-888-HMO-9050
• 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048 (24 hours a day/7 days a week)

We conduct drug utilization review for all our members to make sure that they are getting 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 medications errors.
• Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition.
• Drugs that are inappropriate because of your gender or age.
• Possible harmful interactions between drugs you are taking.
• Drug allergies.
• Drug dosage errors.

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

For certain prescription drugs, we have additional requirements or coverage limits. These requirements ensure that our members use their drugs in the most cost effective way and help us control costs. These requirements, developed by a team of doctors and pharmacists, help us provide quality coverage to our members.

Prior Authorization

We require prior authorization for certain drugs. Your physician or provider will help you get approval from us before you fill your prescription. If they don't get approval, we may not cover the drug.

• Request For Medicare Prescription Drug Coverage Determination
  Solicitud de Determinacion de Cobertura de Medicamentos Recetados de Medicare

Quantity Limits

For certain drugs, we limit the amount we will cover per prescription for a defined period of time. For example, we provide up to 60 pills in a 30-day period for Celebrex.

Generic Substitution

When there is a generic version of a brand-name drug available, our network pharmacies automatically give you the generic version.

See our drug list to find out which drugs are subject to these additional requirements. You can ask us to make an exception if one of your drugs has additional requirements. See how to request an exception under "How to request an exception if your drug is not on our list" above.

• You are a new Blue Cross of Idaho Medicare Advantage member who enrolls in a plan with prescription drug coverage
• You are new to Medicare or recently eligible for Part D prescription drug coverage
• You reside in a long-term care facility
• You are a current Blue Cross of Idaho Medicare Advantage member and you change from one of our plans to another
• You are a current Blue Cross of Idaho member who has a negative impact from our yearly drug list changes. Changes can include when we remove medications and/or add prior authorization or step therapy requirements to drugs on our list.

The transition period for current members happens within the first 90-days of any yearly drug list changes. During this time, you can get a one-month supply of prescriptions that we remove from our drug list, have new step therapy or prior authorization requirements, or  change quantity limits. Any current prior authorizations you have remain effective through their expiration date.

New members have a 90-day transition period after they enroll in our plan. During this time, you may obtain a one-month supply of your prescriptions that are not on our drug list, have a step therapy or prior authorization requirements, or quantity limits. After you receive a temporary one-month supply, you should speak with your provider about formulary alternatives, or requesting an authorization or exception. We will send you information about the next year’s plan and drug list changes in the fall of each year.

Within the first 90-days of moving to a long-term care facility, you can receive a one-month supply transition fill. After 90-days you may also be able to get a 31-day emergency supply every 30 days if a drug list exception or a prior authorization request is pending. Even if it’s too soon, you can refill your prescriptions when you move into or out of a long-term care facility.

What you pay during a transition period depends on the tier level of the drug, if the drug is not on our list you pay the cost of our non-drug list exception tier. Members who qualify for assistance pay an amount pre-determined by their level of assistance.

We mail you a letter within three days after receiving your transition supply of drugs. The letter explains how you can request an exception and encourages you to discuss your medications with your provider. Remember to bring your new drug list when you see your provider. We may also let your provider know about your transition supply of drugs.

• Medicare Part B drugs or drugs excluded from Medicare Part D coverage
• Drugs that need prior authorization to determine if they are covered under Medicare Part B or Part D
• Drugs the Food and Drug Administration (FDA) has safety concerns about. (We will cover these drugs if we have an existing prior authorization in place.)

We may not process some transition drug supplies because the FDA recommended dosage or quantity limit is less than what your provider prescribed. Your pharmacist may reduce what you get to the FDA limit in order to give you time to talk to your provider about another drug or a formulary exception.

When you have a change in your level of care, like admission to a long-term care facility, you may need more medication. Requests for more medication may be denied if you ask for a refill too soon. If this happens, your pharmacy can ask us to override the denial in order to refill your prescription.

We cover emergency supplies of non-list Part D drugs if you are outside your 90-day transition period and you are living in a long-term care facility. You can get a 31-day supply or the total amount of the medicine prescribed, whichever is less. We suggest you use the time of your emergency supply to ask for an exception.

You should first ask your provider to help you with an exception. They can call our pharmacy benefits administrator using the number on the back of your prescription ID card. A decision about your request is made within 72 hours or less. If your provider believes your health is at risk by waiting 72 hours, they can ask for an expedited exception and a decision is made within 24 hours or less. You have the right to an appeal if your exception request is denied. You or your provider can get prior authorization and exception forms on this website or the provider portal (link takes you away from the Medicare website), or by calling us at 1-855-479-3661, TTY users can call 711. We are available 24 hours a day, seven days a week.