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Prescription Blue PDP Premium
20 2021 Standard Comprehensive
21 Formulary .
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT
THE DRUGS WE COVER IN THIS PLAN.
This formulary was updated on December 1, 2021. For more recent
information or other questions, please contact us, Prescription Blue PDP
Customer Service, at 1‑800‑565‑1770 or, for TTY users, 711, Monday through
Friday, 8 a.m. to 9 p.m. Eastern time. From October 1 through March 31,
hours are from 8 a.m. to 9 p.m. Eastern time, seven days a week, or visit
www.bcbsm.com/medicare.
TIP When visiting your doctor(s), please bring your personal drug list
and this 2021 Blue Cross Drug List with you.
Updated: 12/01/2021
Formulary 21363, Version 18
www.bcbsm.com/medicare
Prescription
Drug Plans
Note to existing members: This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us,” or “our,” it means Blue Cross Blue Shield
of Michigan. When it refers to “plan” or “our plan,” it means Prescription Blue PDP.
This document includes a list of the drugs (formulary) for our plan which is current as of
December 1, 2021. For an updated formulary, please contact us. Our contact information,
along with the date we last updated the formulary, appears on the front and back
cover pages.
You must generally use network pharmacies to use your prescription drug benefit.
Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on
January 1, 2022, and from time to time during the year.
What is the Prescription Blue PDP changes based on new clinical guidelines. If we
Premium Standard Formulary? remove drugs from our formulary, or add prior
A formulary is a list of covered drugs selected by authorization, quantity limits and/or step therapy
Prescription Blue PDP in consultation with a team restrictions on a drug or move a drug to a higher
of health care providers, which represents the cost-sharing tier, we must notify affected members
prescription therapies believed to be a necessary part of the change at least 30 days before the change
of a quality treatment program. Prescription Blue PDP becomes effective, or at the time the member
will generally cover the drugs listed in our formulary as requests a refill of the drug, at which time the
long as the drug is medically necessary, the prescription member will receive a 31-day supply of the drug.
– If we make these other changes, you or your
is filled at a Prescription Blue PDP network pharmacy,
and other plan rules are followed. For more information prescriber can ask us to make an exception
on how to fill your prescriptions, please review your and continue to cover the brand-name drug for
Evidence of Coverage. you. The notice we provide you will also include
information on how to request an exception,
and you can also find information in the section
Can the Formulary (drug list) change? below entitled “How do I request an exception to
the Prescription Blue PDP Premium Standard
Most changes in drug coverage happen on January 1,
but we may add or remove drugs on the Drug List Formulary?”
during the year, move them to different cost-sharing Changes that will not affect you if you are currently
tiers, or add new restrictions. We must follow Medicare taking the drug. Generally, if you are taking a drug on
rules in making these changes. our 2021 formulary that was covered at the beginning
Changes that can affect you this year: In the below of the year, we will not discontinue or reduce coverage
cases, you will be affected by coverage changes of the drug during the 2021 coverage year except as
during the year: described above. This means these drugs will remain
available at the same cost-sharing and with no new
Drugs removed from the market. If the Food restrictions for those members taking them for the
and Drug Administration deems a drug on our remainder of the coverage year. You will not get direct
formulary to be unsafe or the drug’s manufacturer notice this year about changes that do not affect you.
removes the drug from the market, we will However, on January 1 of the next year, such changes
immediately remove the drug from our formulary would affect you, and it is important to check the Drug
and provide notice to members who take the drug.
List for the new benefit year for any changes to drugs.
Other changes. We may make other changes
The enclosed formulary is current as of
that affect members currently taking a drug. For December 1, 2021. To get updated information about
instance, we may add a generic drug that is not the drugs covered by Prescription Blue PDP, please
new to market to replace a brand-name drug contact us. Our contact information appears on the
currently on the formulary or add new restrictions front and back cover pages. In the event of a mid-year
to the brand-name drug or move it to a different non-maintenance formulary change, we will send out
cost-sharing tier or both. Or we may make an errata sheet to notify you of this change.
Updated: 12/01/2021 i
How do I use the Formulary? Are there any restrictions on my coverage?
There are two ways to find your drug within Some covered drugs may have additional
the formulary: requirements or limits on coverage. These
Medical Condition requirements and limits may include:
The formulary begins on page 1. The drugs Prior Authorization: Prescription Blue PDP
in this formulary are grouped into categories requires you or your physician to get prior
depending on the type of medical conditions that authorization for certain drugs. This means that
they are used to treat. For example, drugs used you will need to get approval from Prescription
to treat a heart condition are listed under the Blue PDP before you fill your prescriptions. If you
category, “Cardiovascular Agents.” If you know don’t get approval, Prescription Blue PDP may
what your drug is used for, look for the category not cover the drug.
name in the list that begins on page 1. Then look Quantity Limits: For certain drugs,
under the category name for your drug. Prescription Blue PDP limits the amount of
Alphabetical Listing the drug that Prescription Blue PDP will cover.
For example, Prescription Blue PDP provides
If you are not sure what category to look under, thirty-one tablets per prescription for pioglitazone.
you should look for your drug in the Index that This may be in addition to a standard one-month
begins on page Index 1. The Index provides or three-month supply.
an alphabetical list of all of the drugs included
in this document. Both brand-name drugs and Step Therapy: In some cases, Prescription
generic drugs are listed in the Index. Look in Blue PDP requires you to first try certain drugs to
the Index and find your drug. Next to your treat your medical condition before we will cover
drug, you will see the page number where another drug for that condition. For example,
you can find coverage information. Turn to the if Drug A and Drug B both treat your medical
page listed in the Index and find the name of condition, Prescription Blue PDP may not cover
your drug in the first column of the list. Drug B unless you try Drug A first. If Drug A does
not work for you, Prescription Blue PDP will then
cover Drug B.
What are generic drugs? You can find out if your drug has any additional
Prescription Blue PDP covers both brand-name drugs requirements or limits by looking in the formulary that
and generic drugs. A generic drug is approved by begins on page 1. You can also get more information
the FDA as having the same active ingredient as the about the restrictions applied to specific covered
brand-name drug. Generally, generic drugs cost less drugs by visiting our website. We have posted online
than brand-name drugs. a document that explains our prior authorization and
step therapy restrictions. You may also ask us to send
you a copy. Our contact information, along with the
date we last updated the formulary, appears on the
front and back cover pages.
You can ask Prescription Blue PDP to make an
exception to these restrictions or limits or for a list
of other, similar drugs that may treat your health
condition. See the section, “How do I request an
exception to the Prescription Blue PDP Premium
formulary?” on page iii for information about how to
request an exception.
ii Updated: 12/01/2021
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