Frequently Asked Questions

Medicare Supplement FAQs: Click here

General FAQs

If I purchase a BlueAdvantage plan, will I lose my Medicare coverage?

No. Medicare Advantage plans are part of the Medicare program and provide Medicare coverage. These plans are administered by private insurance companies under contract with the Medicare program.

Does BlueAdvantage cover the same services as Original Medicare?

Yes. BlueAdvantage covers the same types of services that Original Medicare covers, plus some additional services not covered by Original Medicare. Please see the Summary of Benefits for a comparison of covered services. Hospice care is still covered under Original Medicare and you should show your Medicare Card for hospice care.

Why do I have to pay my Medicare Part B premium if this plan replaces my Medicare and if Medicare isn’t paying my claims?

BlueCross BlueShield of Tennessee and other Medicare Advantage insurance companies have a contract with Medicare to provide your Part A and Part B coverage. As part of this contract, the plan receives payments from Medicare to cover the cost of your benefits. Your Part B premium, along with the premium you pay for the plan, make up the total premium needed to provide your Medicare Advantage benefits.

Will I still need to show my Medicare card when receiving health care services?

No. If you enroll in this plan, you will show your BlueAdvantage card each time you receive health care services. However, you should keep your Medicare card in a safe place.

Is there a waiting period before benefits will be paid on pre-existing medical conditions?

No. There isn’t a pre-existing condition waiting period except for BlueElite and BlueCross65 members. Please see the Medicare Supplement FAQs for additional information.   

Do I have to choose a primary care physician?

No. You are not required to select one doctor to receive general care or to serve as a gatekeeper for your medical care.

Do I need a referral to see a specialist?

No. You are free to see any specialist you like.

Once I select a Medicare Advantage plan, can I change plans later?

Yes.  Each year you can start over with a different plan during the annual coordinated election period, from November 15 through December 31, for coverage beginning January 1 of the following year. Additionally, you have the opportunity to change one time during the open enrollment period, from January 1 to March 31.

Please be aware that your options during open enrollment are limited based on the type of plan you are enrolled in the year before January 1. Once the open enrollment period ends on March 31, you may not make any more plan changes until the next annual coordinated election period, unless you qualify for a special enrollment period.

What happens to my coverage if BlueCross BlueShield of Tennessee leaves the Medicare program? Can I go back to Original Medicare Part  A and Part B?

All health plans with Medicare contracts agree to stay with the Medicare program for a full year, but coverage from a particular plan beyond the current year is not guaranteed. Each year, plans can decide if they wish to continue for another year. The Centers of Medicare and Medicaid Services, which administers Medicare and other programs under the umbrella of the U.S. Department of Health & Human Services, can also decide not to renew a plan’s contract.

If a plan leaves the Medicare program, you will not lose Medicare coverage. You will receive notification 90 days in advance along with information about your other Medicare coverage options. 

Will my BlueAdvantage and BlueRx monthly premiums or benefits change next year? 

The BlueAdvantage contract is renewed annually with Medicare. The premiums, benefits, copays and coinsurance amounts can change annually. Members will receive an annual notice of change in the mail by October 31 for changes effective the following January 1. Also, remember that everyone has the opportunity to change plans each year during the annual coordinated election period from November 15 to December 31. 

 

Plan-Specific FAQs

What can I expect from my BlueAdvantage PPO coverage if I go to an out-of-network provider in an emergency situation? 

In case of an emergency, you should always seek medical care from the closest available provider. You will receive in-network benefits for emergency care you receive even if the provider is not in the BlueAdvantage PPO network.

Will out-of-state doctors accept my BlueAdvantage PPO plan if I’m traveling?

With BlueAdvantage PPO, you are free to seek care from any health care provider that accepts Medicare payments and the terms, conditions and payment rates of our plan. However, you must present your BlueAdvantage PPO ID card before you receive services. The same terms and conditions apply to in-state and out-of-state doctors. You must present your BlueAdvantage ID card before you receive services.

Can I enroll in another Medicare Part D plan with BlueAdvantage PPO Sapphire or Diamond?

No. You must get your prescription drug benefits through your BlueAdvantage PPO plan.

Can I enroll in a BlueAdvantage PFFS medical-only plan and purchase a separate prescription drug plan for my Medicare Part D coverage?

Yes. If you want prescription drug coverage, you can enroll in BlueRx, our standalone prescription drug plan, or purchase prescription drug coverage from another insurance company. You may also want to consider one of our BlueAdvantage PFFS plan options with prescription drug coverage included.

Can I enroll in another Medicare Part D plan with BlueAdvantage PFFS Gold and Platinum?

No. You must get your prescription drug benefits through your BlueAdvantage PFFS Gold or Platinum.

 

Prescription Drug Coverage FAQs

What is a formulary?

A formulary is a list of covered drugs provided by the plan. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other coverage rules are followed. For certain prescription drugs, we have additional requirements for coverage or limits on our coverage.

How are drugs on the formulary selected?

The drugs on the formulary are selected by our plan with the help of a team of health care providers. We select the prescription therapies believed to be a necessary part of a quality treatment program. Both brand-name drugs and generic drugs are included on the formulary.  A generic drug has the same active ingredient as the brand-name 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 as effective as brand-name drugs.

How do I find out what drugs are on the formulary?

You may call Customer Service to find out if your drug is on the formulary or to request a copy of our formulary.  You may also get updated information about the drugs covered by us by visiting our Web site at www.bcbst-medicare.com

How much will I have to pay for my prescription?

Drugs on our formulary are organized into different drug tiers, or groups of different drug types.  Your coinsurance/co-payment depends on which drug tier your drug is in.

What if my drug isn’t on the formulary?

If your prescription isn’t listed on the formulary, you should first contact Customer Service to be sure it isn’t covered. If Customer Service confirms that we don’t cover your drug, you have three options:

• You may ask your doctor if you can switch to another drug that is covered by us. If you would like to give your doctor a list of covered drugs that are used to treat similar medical conditions, please contact Customer Service or go to our formulary Web site.
• You may ask us to make an exception (which is a type of coverage determination) to cover your drug.  See your Evidence of Coverage to learn more about how to request an exception.
• You can pay out-of-pocket for the drug and request that the plan reimburse you by requesting an exception. This doesn’t obligate the plan to reimburse you if the exception request isn’t approved. If the exception isn’t approved, you may appeal the plan’s denial. Please see your Evidence of Coverage for more information on how to request an appeal.

In some cases, we will contact you if you are taking a drug that isn’t on our formulary. We can give you the names of covered drugs that also are used to treat your condition so you can ask your doctor if any of these drugs are an option for your treatment.

What are network pharmacies?

A network pharmacy is a pharmacy that has a contract with us to provide your covered prescription drug. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. Once you go to one, you aren’t required to continue going to the same pharmacy to fill your prescription; you may go to any of our network pharmacies

What is the difference between a preferred and non-preferred brand-name and generic drugs?

Preferred drugs are therapeutically sound, cost-effective brand-name and generic drugs that we encourage members to use drugs listed in the formulary (list of drugs). Using preferred drugs helps you save money. You will pay a lower copay for preferred generic drugs and preferred brand-name drugs. Non-preferred brand-name drugs and non-preferred generic drugs are drugs that are still covered under your plan, but at a higher copay.   

If the drug is available as a generic drug, do I have to take the generic?

If a brand-name drug has a generic equivalent available, and only the generic drug is on the formulary, you can purchase the brand-name drug, but you will be responsible for the total cost. These costs will not count toward your initial coverage limit or the catastrophic coverage threshold. Please talk to your doctor about switching to generics if a generic is available and appropriate for your treatment.

How do I file my prescription drug claims?

To receive benefits for prescription drugs, you must purchase your drugs at a pharmacy that participates in the BlueAdvantage/BlueRx pharmacy network. These participating network pharmacies will submit your claims electronically, and you will only pay the applicable copay amounts. If you are in the coverage gap phase, you still need to use a participating network pharmacy. Show your BlueCross BlueShield of Tennessee ID card to make sure that you receive the network discount price. Showing your ID will also ensure that your out-of-pockets costs count toward your catastrophic coverage threshold.

Are all of my prescription drugs covered under BlueAdvantage and BlueRx?

BlueAdvantage uses a formulary, which is a list of drugs selected to meet patient needs. Your drug must be listed on the formulary for it to be covered. Some drugs that may be listed on the formulary may be covered under the Medicare Part B portion of your coverage, depending on the reason you are taking the drug and the setting in which you receive it. This means that your Part D copays and benefits will not apply to these drugs, even though they may be listed in the formulary.

Examples of the types of drugs that may be subject to Part B coverage include:

• Some antigens - If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under a doctor’s supervision

• Osteoporosis drugs - Injectable drugs for osteoporosis for certain women with Medicare

• Erythropoietin (Epoetin alpha or Epogen®) - By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia

• Hemophilia clotting factors - Self-administered clotting factors if you have hemophilia

• Injectable drugs - Most injectable drugs are administered incident to a physician’s service

• Immunosuppressive drugs - Immunosuppressive drug therapy for transplant patients if the transplant was paid by Medicare or paid by a private insurance company that paid as a primary payer to your Medicare Part A coverage in a Medicare-certified

• Some oral cancer drugs - If the same drug is available in injectable form

• Oral anti-nausea drugs - If the drug is part of an anti-cancer chemotherapeutic regimen

• Inhalation and infusion drugs - Provided through a durable medical equipment supplier

These Part B costs will not count toward your initial coverage limit or the catastrophic coverage threshold.

Can I purchase any prescription through the mail order prescription drug program? 

The program is designed to cover drugs which are used to treat chronic conditions and are taken for a period of 30 days or longer.

Who do I contact for mail order service? 

You may choose CVS CareMark or Walgreens for your mail order service. If you have questions or need more information, feel free to contact the pharmacy of your choice at the numbers listed below:

CVS CareMark
1-800-311-0485 (TTY: 1-800-311-0533)
Monday through Friday, 8 a.m. to 8 p.m. Eastern Time
Saturday, 9 a.m. to 6 p.m. Eastern Time
Sunday, 10 a.m. to 6 p.m. Eastern Time
CVS CareMark Order Form
CVS CareMark Mail Order Brochure

Walgreens  
1-800-489-2197 (TTY: 1-800-925-0178)
Monday through Friday, 8 a.m. to 10  p.m. Eastern Time
Saturday and Sunday, 8 a.m. to 5 p.m. Eastern Time
Walgreens Mail Service Order Form

When will I receive my mail order prescriptions? 

Your prescriptions will be delivered to you, postage paid by the U.S. Mail or other carrier, within approximately 14 days from receipt of the order. Prescriptions can be shipped via overnight carrier for an additional charge.

Will I get generic or brand name drugs through the mail order pharmacy? 

That depends on you and your doctor. If you wish to obtain a brand name drug when a generic is available, your doctor must write "dispense as written" or "brand necessary" on the prescription. Generic drugs are equal in effectiveness and safety to brand name drugs. They contain the same active ingredients, have the same degree of purity, the same potency and the same concentration as their brand name counterparts. Yet, generic drugs generally offer savings of greater than 50 percent when compared to the brand name products.

How do I obtain refills through the mail order pharmacy?

Do one of the following at least two weeks before your current supply will run out. Be prepared to provide your date of birth, your member ID number, your prescription number(s) and your credit card information.

• By mail: Complete the refill order envelope received with your previous prescription order. Mail it with your refill slips and payment.
• By phone:
  • Call CVS CareMark at 1-800-311-0485 (TTY: 1 800 311-0533) Monday through Friday, 8 a.m. to 8 p.m., Saturday 9 a.m. to 6 p.m. or Sunday 10 a.m. to 6 p.m. Eastern Time
  • Call Walgreens at 1-800-489-2197 (TTY: 1 800 925-0178) Monday through Friday, 8 a.m. to 10  p.m., Saturday and Sunday 8 a.m. to 5 p.m. Eastern Time.

Note: 60 percent of the supply must be used as prescribed before a prescription for the same medication can be refilled. Early reorders will be held until the refill is allowed.

What if I have no refills left on my mail order prescription? 

If your prescription label indicates "0" refills or if your refill request states "your prescription has expired," please do the following:

1. Request a new prescription from your doctor.
2. Mail the new prescription directly to CVS CareMark or Walgreens along with your payment and completed order form to the appropriate address:
   • CVS CareMark
     P.O. Box 9106
     Clearwater, FL 33758-9922
   • Walgreens Mail Service
     P.O. Box 628001
     Orlando, FL 32862-8001

How can I enroll in the mail order prescription drug program? 

1. Select the mail order pharmacy you wish to use.
2. Complete the order form that is included in your enrollment packet or print one from the link below.
3. Ask your physician to write two prescriptions:
1. one for an initial 90-day supply to be filled by your local pharmacy
2. one for the mail order prescription drug program with appropriate refills
4. Mail your order form, your original written prescription(s) and payment (check, money order or credit card information) to the appropriate address:

• CVS CareMark
  P.O. Box 9106
  Clearwater, FL 33758-9922
  CVS CareMark Order Form
  CVS CareMark Mail Order Brochure

• Walgreens Mail Service
  P.O. Box 628001
  Orlando, FL 32862-8001
  Walgreens Order Form

For frequently asked questions about our Medicare Supplement plan, BlueCross 65, Click here.