2016 PHARMACY. Benefit Summary Book. RXSUMBK2016

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1 2016 Benefit Summary Book RXSUMBK2016

2 REVIEW THIS SUMMARY BOOKLET TO LEARN HOW TO GET THE MOST FROM YOUR PRESCRIPTION BENEFIT. THIS INCLUDES INFORMATION ABOUT: n Your prescription drug benefits n Your formulary and cost share n Highlights from your health plan n Ways to save money YOUR PRESCRIPTION DRUG BENEFIT The Blue Cross and Blue Shield Service Benefit Plan works with CVS/caremark to administer your prescription benefit. CVS/caremark is an independent company called a Pharmacy Benefit Manager (PBM). The PBM manages your: n Retail Pharmacy Program n Mail Service Pharmacy Program n Specialty Pharmacy Program GENERAL QUESTIONS If you have any questions about your benefits, please: n See your Blue Cross and Blue Shield Service Benefit Plan brochure (RI ) n Visit n Call CVS/caremark Customer Care any time toll-free at TABLE OF CONTENTS YOUR PRESCRIPTION DRUG BENEFIT...2 Member Pharmacy Options n Preferred Retail Pharmacy n Mail Service Pharmacy Program n Specialty Pharmacy Program n Non-preferred Retail Pharmacy Formulary Covered Services and Limitations Quantity Limits Prior Approval Specialty YOUR COST SHARE...9 Cost Tiers Pharmacy Cost Share Tiers Medicare Part B Primary Cost Share Tiers WAYS TO SAVE...18 Be a Smart Consumer Partner with Your Doctor and Pharmacist Manage Your Health and Your Money with Generics Use Preferred Brand Name Use Mail Service Pharmacy Use a Preferred Retail Pharmacy BENEFIT HIGHLIGHTS...21 Contraceptive Benefit Diabetic Benefit Wellness Benefit FILLING A PRESCRIPTION...24 Preferred Retail Pharmacy Mail Service Pharmacy Specialty Pharmacy FILING A CLAIM...26 Non-preferred Retail Pharmacy Overseas Supplementary Providers HOW TO CONTACT US

3 YOUR PRESCRIPTION DRUG BENEFIT Understanding your prescription benefit will save you time and money. Your Basic or Standard Option benefits will cover much of your prescription cost. BENEFIT OPTIONS You have four options for obtaining the prescription drug you need. PREFERRED RETAIL PHARMACIES Service Benefit Plan members have access to more than 65,000 Preferred retail pharmacies across the country. To fill a prescription at one of our Preferred retail pharmacies, simply show your ID card when submitting your prescription. You will only pay your cost share, there are no deductibles under the pharmacy benefit. To find a Preferred pharmacy near you: n Visit and click on the Pharmacy link. n Call CVS/caremark Customer Care any time toll-free at Basic Option members must fill prescriptions at a Preferred retail pharmacy, your benefits are not available outside the Preferred network. MAIL SERVICE PROGRAM For Standard Option members and members who have Basic Option and Medicare B primary, the Mail Service Pharmacy Program is a convenient and cost-effective way to get your maintenance or long-term drugs. These are drugs you take regularly, and need to take long-term. Examples might include drugs for high blood pressure, arthritis, or other chronic conditions. You can get a 90-day supply (minimum 22-day supply) of long-term drugs for one copayment. Choose to have these drugs sent to your home, office, or a location of your choice with free standard shipping. Using Mail Service saves you time by avoiding trips to the pharmacy. Basic Option members without Medicare B primary do not have Mail Service benefits. SPECIALTY PROGRAM The Specialty Pharmacy Program is administered by CVS/caremark Specialty Pharmacy, which offers a number of advantages to Basic and Standard Option members and their doctors. In addition to specialty drugs, the Specialty Pharmacy Program provides personalized pharmacy care management services including: n Access to an on-call pharmacist 24 hours a day, seven days a week. n Drug and disease-specific education and counseling through an assigned CareTeam, a group of clinical professionals available to review dosing and drug schedules, troubleshoot injection-related issues, discuss potential side effects, and share educational information to help you effectively manage your condition. 2 3

4 YOUR PRESCRIPTION DRUG BENEFIT n Coordination of care with you and your doctor. n Convenient delivery directly to you or your doctor s office in a temperature-controlled secure package with required ancillary supplies, such as needles, syringes, disposal containers, and alcohol wipes. n Online support through including disease-specific information and opportunity to submit questions to pharmacists and nurses. NON-PREFERRED RETAIL PHARMACIES If you are a Standard Option member, you may purchase your prescription drugs and supplies from Non-preferred retail pharmacies. However, you will be asked to pay the full amount for these items and then file a Retail Prescription Drug Claim for reimbursement. n To download a Retail Prescription Drug Claim Form go to and click on Find a Form. n Call to obtain a form. Basic Option members must use a Preferred retail pharmacy. FORMULARY The formulary is a complete list of your covered prescription drugs. It includes generic, brand name, and specialty drugs as well as Preferred drugs that, when selected, will lower your out-of-pocket costs. The formulary has five tiers of drugs. (See tier chart on page 9.) BASIC OPTION (FORMULARY) Select drugs will no longer be covered on the Basic Option drug formulary. These drugs known as Managed Not Covered drugs have available covered options in the same therapeutic class. For a full listing of Managed Not Covered drugs and available covered options: n Visit and click on the Pharmacy link. n Call CVS/caremark any time toll-free at Basic Option members taking a Managed Not Covered drug should expect to pay the full cost of the prescription. HOW A FORMULARY IS DETERMINED The Pharmacy and Medical Policy Committee (PMPC) is an independent group of doctors and pharmacists. This group recommends drugs for each tier based on their: n Effectiveness n Safety n How they compare to other drugs in the same therapeutic class The PMPC meets every quarter to review new drugs and other changes to the formulary. may change tiers or prior approval status. Read on to learn about prior approval, and check your formulary often to be aware of any changes. 4 5

5 YOUR PRESCRIPTION DRUG BENEFIT COVERED SERVICES AND LIMITATIONS Our Pharmacy Programs staff continually reviews drugs in support of safe and appropriate therapies. This review helps ensure that drugs in your benefit plan work well and are cost effective. QUANTITY LIMITS Certain drugs on the formulary have quantity limits, which means your pharmacy benefit will only cover up to a specified, limited amount of the drug each time you fill a prescription or a limited amount per year. Quantity limits are often applied to ensure drugs are used safely and appropriately. PRIOR APPROVAL Some prescription drugs and supplies need approval in advance, or prior approval before we provide coverage for them. We need to find out if: n The drug is related to a service or condition that is covered under the Service Benefit Plan and n The drug is prescribed in a way that matches generally accepted medical practices. FACTS TO KNOW ABOUT PRIOR APPROVAL n In providing prior approval, we may limit the amount of drug you can receive. We approve drug quantities (for example, number of pills) based on accepted standards of medical, dental, or psychiatric practice in the United States. n You ll need to renew your prior approval periodically. n and supplies on the Prior Approval list may change throughout the year. n Mail Service and Specialty Programs will not fill prescriptions that need prior approval until you receive prior approval. n Preferred retail pharmacies will fill your prescriptions, but you will pay full cost until you get prior approval. File a claim for reimbursement with the Retail Pharmacy Program. THE PRIOR APPROVAL LIST For a list of drugs that need prior approval or to get a prior approval request form: n Visit and click on the Pharmacy link. n Call CVS/caremark any time toll-free at

6 YOUR COST SHARE SPECIALTY DRUGS A specialty prescription drug is used to treat complex health conditions. Specialty drugs are usually high in cost and have one or more of these elements: n Are injectable n Are infused n Are inhaled n Are products of biotechnology n Have special requirements for handling, shipping, and storage n Need specialized patient training and coordination of care FACTS TO KNOW ABOUT SPECIALTY DRUGS n Specialty drugs in Tier 4 are Preferred. n Specialty drugs in Tier 5 are Non-preferred. 8 n You may fill one 30-day supply of a specialty drug (Tier 4 or Tier 5) at a Preferred retail pharmacy. n After your first fill at a Preferred retail pharmacy, all additional refills of the same specialty drug must be filled through the Specialty Pharmacy Program. n You are limited to a 30-day supply for the first three fills of each specialty drug. You can get a 90-day supply after the third fill. To access the Specialty Drug List: n Visit and click on the Pharmacy link. n Call the CVS/caremark Specialty Pharmacy toll-free at The costs of drugs vary. How much you pay is your cost share. Look for your drug in the five-tier formulary for your plan option. The tier level where your drug type is listed determines your cost. HOW TIERS RELATE TO COSTS Basic and Standard Options TIER Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 DRUG TYPE Generic. Typically the most affordable, and are equal to their brand name counterparts in quality, performance characteristics and intended use. Preferred Brand Name. Proven to be safe, effective, and favorably priced compared to Non-preferred brands. Non-preferred Brand Name. These drugs have either a generic or Preferred brand available therefore your cost share will be higher. Preferred Specialty. Proven to be safe, effective, and favorably priced compared to Non-preferred specialty drugs. Non-preferred Specialty. These drugs typically have a Preferred brand available therefore your cost share will be higher. Generally, the lower the drug tier, the lower the cost. Generic drugs (Tier 1) and Preferred brand name drugs (Tier 2) provide you with high-quality, cost-effective options. If you are taking a prescription drug and want to know your cost share: n Visit and click on the Pharmacy link. n Call CVS/caremark any time toll-free at

7 YOUR COST SHARE BASIC OPTION COST SHARE TIERS Basic Option members must use a Preferred retail pharmacy and will save by choosing generic drugs and Preferred brand name drugs when possible. Use the charts below to determine your cost share. BASIC OPTION: Cost Share Based on Where You Fill Your Prescription * Basic Option Members with Medicare B primary coverage have Mail Service Pharmacy benefits. See charts on page TIER Tier 1: Generic Tier 2: Preferred Brand Name Tier 3: Non-preferred Brand Name PREFERRED RETAIL --Up to $10 --You can get up to a 30-day supply for 1 copayment or a 90-day supply for 3 copayments -- Up to $50 -- You can get up to a 30-day supply for 1 copayment or a 90-day supply for 3 copayments --60% of the drug price when the price is $110 or greater --$65 copayment or the drug price when the price is less than $110 --You can get up to a 30-day supply for 1 copayment or a 90-day supply for 3 copayments NON-PREFERRED RETAIL & MAIL SERVICE Not covered* BASIC OPTION: Specialty - Cost Share Based on Where You Fill Your Prescription TIER SPECIALTY PREFERRED RETAIL Tier 4: Preferred Specialty Tier 5: Non-preferred Specialty --Up to $55 for 30-day supply or $165 for 31 to 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get a 90-day supply after the 3rd fill --Up to $80 for 30-day supply or $240 for 31 to 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get a 90-day supply after the 3rd fill -- Up to $65 for up to a 30-day supply only -- When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy --Up to $90 for up to a 30-day supply only - - When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy 11

8 YOUR COST SHARE STANDARD OPTION COST SHARE TIERS Standard Option members save by using the Mail Service Pharmacy and Preferred retail pharmacies for filling prescription drugs. Members can also save by asking for generic drugs and Preferred brand name drugs when possible. Use the charts below to determine your cost share. STANDARD OPTION: Cost Share Based on Where You Fill Your Prescription TIER Tier 1: Generic Tier 2: Preferred Brand Name Tier 3: Nonpreferred Brand Name MAIL SERVICE PREFERRED RETAIL --Up to $15* --20% of the Plan allowance* --Up to $ % of the Plan allowance --Up to $ % of the Plan allowance NON-PREFERRED RETAIL --45% of the average wholesale price plus any difference between the allowance and the billed amount --If you use a Non-preferred retail pharmacy, you need to file a paper claim for reimbursement STANDARD OPTION: Specialty - Cost Share Based on Where You Fill Your Prescription TIER Tier 4: Preferred Specialty Tier 5: Nonpreferred Specialty SPECIALTY --$35 for up to 30-day supply --$95 for 31 to 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get a 90-day supply after the 3rd fill --Up to $55 for 30-day supply --$155 for 31 to 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get a 90-day supply after the 3rd fill PREFERRED RETAIL --30% of the Plan allowance - up to 30-day supply --When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy NON-PREFERRED RETAIL --45% of the average wholesale price plus any difference between the allowance and the billed amount --When you buy specialty drugs at a Non-preferred retail pharmacy, you are limited to one 30- day supply for each prescription. You must get all refills through the Specialty Pharmacy * Lower cost shares are available to Standard Option members with Medicare Part B primary. See charts on page

9 YOUR COST SHARE BASIC OPTION MEDICARE PART B PRIMARY COST SHARE TIERS If you have Medicare Part B as your primary payer you can lower your cost share on your prescription drugs. Use the charts below to determine your cost share. BASIC OPTION NOW HAS MAIL SERVICE Good news. Members who have Basic Option with Medicare B primary can now choose to use the Mail Service Pharmacy as well as Preferred retail pharmacies for more savings and the added convenience of having your drugs delivered to your door. BASIC OPTION MEDICARE B PRIMARY: Your Cost Share Based on Where You Fill Your Prescription TIER MAIL SERVICE PREFERRED RETAIL NON-PREFERRED RETAIL BASIC OPTION MEDICARE B PRIMARY: Specialty - Your Cost Share Based on Where You Fill Your Prescription Tier 1: Generic Tier 2: Preferred Brand Name Tier 3: Nonpreferred Brand Name --Up to $20 --Up to $10 --Up to $90 --Up to $45 --You can get up to a 30-day supply for 1 copayment or a 90-day supply for 3 copayments --You can get up to a 30-day supply for 1 copayment or a 90-day supply for 3 copayments --Up to $ % of the drug price when the price is $110 or greater --$55 copayment or the drug price when the price is less than $ You can get up to a 30-day supply for 1 copayment or a 90-day supply for 3 copayments Not Covered TIER SPECIALTY PREFERRED RETAIL Tier 4: Preferred Specialty Tier 5: Nonpreferred Specialty --Up to $50 for 30-day supply or $140 for 31 to 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get a 90-day supply after the 3rd fill --Up to $70 for 30-day supply or $195 for 31 to 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get a 90-day supply after the 3rd fill --Up to $60 for up to a 30-day supply only --When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy --Up to $80 for up to a 30-day supply only --When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy 14 15

10 YOUR COST SHARE STANDARD OPTION MEDICARE PART B PRIMARY COST SHARE TIERS If you have Standard Option with Medicare Part B as your primary payer you can enjoy lower copays at the pharmacy and through the Mail Service Pharmacy. Use the charts below to determine your cost share. STANDARD OPTION MEDICARE B PRIMARY: Your Cost Share Based on Where You Fill Your Prescription TIER Tier 1: Generic Tier 2: Preferred Brand Name Tier 3: Nonpreferred Brand Name MAIL SERVICE -Up - to $10 -Up - to $80 -Up - to $105 PREFERRED RETAIL -15% - of the Plan allowance --30% of the Plan allowance --45% of the Plan allowance NON-PREFERRED RETAIL --45% of the average wholesale price plus any difference between the allowance and the billed amount --If you use a Nonpreferred retail pharmacy, you need to file a paper claim for reimbursement STANDARD OPTION MEDICARE B PRIMARY: Specialty - Your Cost Share Based on Where You Fill Your Prescription TIER Tier 4: Preferred Specialty Tier 5: Nonpreferred Specialty SPECIALTY --$35 for up to 30-day supply --$95 for 31 to 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get a 90-day supply after the 3rd fill --Up to $55 for 30-day supply --$155 for 31 to 90-day supply - - You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get a 90-day supply after the 3rd fill PREFERRED RETAIL --30% of the Plan allowance - up to 30-day supply --When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy NON-PREFERRED RETAIL --45% of the average wholesale price plus any difference between the allowance and the billed amount --When you buy specialty drugs at a Non-preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy 16 17

11 WAYS TO SAVE 1. BE A SMART CONSUMER. Each year, the prescription drug industry spends more than $4 billion to promote its brands. Those costs are passed along to insurance companies, businesses, and you. So choose a drug based on its effectiveness, not its advertising slogan. 2. PARTNER WITH YOUR DOCTOR AND PHARMACIST. Your doctor and pharmacist are key members of your healthcare team. They are the experts on health conditions and the prescription drugs used to treat them. Remember to ask questions if you don t understand something. The more you know about your condition and prescription drugs, the better off you will be. Here are some questions you might ask your doctor or pharmacist: n Why do I need to take this prescription drug? n What is the right way to take it? n How often should I take it? n Should I take it with food or water? n Should I avoid other drugs or foods while I m taking it? n Is this a generic drug? n Is there a generic substitute? n Is there a less expensive drug on my formulary that might be right for me? These are just examples of some questions you might ask. Remember, your doctor or pharmacist has probably heard your question before, so don t be shy to ask. The more you know, the better you ll feel. 3. MANAGE YOUR HEALTH AND YOUR MONEY WITH GENERICS. The FDA requires that generic drugs are equal in quality to their brand name counterpart, and you almost always pay less for generics. Ask your doctor to approve generic substitution when possible. STANDARD OPTION Standard Option members have the option of using the Generic Incentive Program (GIP). When using the GIP, your cost shares for the first four (4) prescriptions filled (and/or refills ordered) per generic drug each calendar year are waived when: n You switch from a brand name drug on the GIP list to a generic drug replacement (not from one generic to another generic), and n You buy both the brand name drug and the corresponding generic drug replacement during the same calendar year

12 WAYS TO SAVE BENEFIT HIGHLIGHTS 4. USE PREFERRED BRAND NAME DRUGS. Preferred brand name drugs have been proven to be safe, effective, and lower in cost. Your cost share is always lower with a Preferred brand name drug compared to a Nonpreferred brand name drug. 5. USE MAIL SERVICE FOR LONG-TERM PRESCRIPTION DRUGS. Standard Option members and Basic Option members with Medicare Part B primary coverage have the convenience and cost-effective option of using the Mail Service Pharmacy to have their drugs delivered to them at no charge. 6. USE A PREFERRED RETAIL. Using a Preferred retail pharmacy saves Standard and Basic Option members money there are no deductibles to meet. You only pay your cost share for each prescription or refill. It s that easy. You don t even have to file a paper claim. If you are a Basic Option member and you get your drug from a Non-preferred retail pharmacy, you pay 100% of the prescription cost. To find a Preferred retail pharmacy near you: n Visit and click on the Pharmacy link. n Call CVS/caremark Customer Care any time toll-free at for the current list of Preferred retail pharmacies. CONTRACEPTIVE BENEFIT BASIC OPTION We waive your cost share for generic contraceptives and brand name contraceptives that have no generic equivalent or alternative. This benefit applies when you use a Preferred retail pharmacy. STANDARD OPTION We waive your cost share for generic contraceptives and brand name contraceptives that have no generic equivalent or alternative. This benefit applies when you use: n A Preferred retail pharmacy n The Mail Service Pharmacy Program Basic or Standard Option contraceptives for women covered with zero cost share include: n Generic contraceptive drugs n Brand name contraceptive drugs that have no generic equivalent or alternative n Over-the-counter (OTC) contraceptive drugs and devices, limited to: - Emergency contraceptive pills - Female condoms - Spermicides - Sponges n Generic devices: at this time, there are no generic equivalents or alternatives for any of the devices on the market. If generic devices become available, we will include them in this coverage with a zero cost share. Examples of devices for which there are currently no generics include: - Diaphragms and contraceptive rings - Injectable contraceptives - IUDs (intrauterine devices) - Implantable contraceptives - Cervical caps - Oral and transdermal contraceptives 20 21

13 BENEFIT HIGHLIGHTS This program covers OTC contraceptive drugs and devices for women in full only when contraceptives meet FDA standards for OTC products. To receive benefits, you must: n Use a Preferred retail pharmacy. n Present the pharmacist with a prescription from your doctor. DIABETIC BENEFIT BASIC OPTION Members may get insulin and diabetic supplies from a Preferred retail pharmacy. STANDARD OPTION Members may get insulin and diabetic supplies from a Preferred or Non-preferred retail pharmacy or the Mail Service Pharmacy Program. PRIMARY COVERAGE WITH MEDICARE PART B You may also receive insulin and diabetic supplies from doctors or other healthcare providers. GET A FREE BLOOD GLUCOSE TEST METER The Diabetic Meter Program offers members with diabetes an ACCU-CHEK or One Touch glucose meter kit at no cost, once per benefit year. Each kit includes a glucose meter, and a starter supply of test strips and lancets. Members can choose from five (5) different meters offered. Call CVS/caremark toll-free at weekdays from 11:00 a.m. to 6:00 p.m. Eastern time to request a meter. You can save money by using Preferred test strips. All five meters offered through this program are compatible with our Preferred (Tier 2) test strips. WELLNESS BENEFIT EARN MONEY FOR PRESCRIPTION COPAYS BY STAYING WELL Our Wellness Incentive Program can help you earn up to a $170 credit on your MyBlue Wellness Card, which can be used for qualified medical expenses like prescription drugs. BLUE HEALTH ASSESSMENT n You can earn $50 the first time you take the confidential Blue Health Assessment (BHA) in n Start by registering or logging onto org/myblue. n Answer questions related to your health, within 10 minutes you ll receive a personalized plan for a healthier you. ONLINE HEALTH COACH After taking the BHA, you can set wellness goals with the Online Health Coach to keep you on the path to success. n Available at no cost to you. n Earn $40 for each goal you complete, up to three. n Sync your Fitbit to the Online Health Coach and automatically track progress of your exercise and weight management goals. OTHER PROGRAMS These are just a few of your pharmacy benefit highlights. Your Service Benefit Plan includes so much more. For other programs such as the Tobacco Cessation Incentive Program, breast pump benefit, Hypertension Management Program, preventive benefits and more, see: n Your Service Benefit Plan brochure (RI ) n The Service Benefit Plan website at

14 FILLING A PRESCRIPTION HOW TO FILL YOUR PREFERRED RETAIL DRUGS To fill a prescription at one of our Preferred retail pharmacies, simply show your member ID card when submitting your prescription. You do not have to file a paper claim. HOW TO ORDER NEW PRESCRIPTIONS THROUGH THE MAIL SERVICE Online: to order prescription drugs or ask about the status of your order any time, visit to register or log in to your MyBlue account. You will be able to manage all of your prescription benefits, and easily order refills. By mail: for each prescription you order, complete a Mail Service Order Form. To request an order form, please call Customer Care toll-free , or visit Mail the form, your prescription, and your copayment to the address on the form: CVS/caremark P.O. Box 1590 Pittsburgh, PA HOW TO FILL YOUR SPECIALTY DRUGS: Make sure your specialty drug is on the Specialty Drug List and have your doctor obtain prior approval if required. To access the Specialty Drug List: n Visit and click on the Pharmacy link. With your prescription information and member ID card available, call, or have your doctor call, the CVS/caremark Specialty Pharmacy toll-free at between the hours of 7:00 a.m. and 9:00 p.m. Eastern time, Monday- Friday and 8:00 a.m. and 6:30 p.m. Eastern time, Saturday and Sunday, or have your doctor fill out the Specialty Drug Order Form and send to: CVS/caremark P.O. Box 1590 Pittsburgh, PA By phone: have your doctor order your new prescriptions by calling the automated CVS/caremark Customer Care line toll-free at

15 FILING A CLAIM HOW TO FILE A CLAIM FOR REIMBURSEMENT FROM A NON- PREFERRED RETAIL : 1. Pay the full price for the prescription. 2. Get an itemized bill. It should include the pharmacy s name and address, patient s name, prescription number, date filled, name of drug or supply, strength, quantity, dosage and charge for each drug or supply. 3. Ask your pharmacist to help you fill out the pharmacy information and prescription information section of the Retail Prescription Drug Claim form. n To download a Retail Prescription Drug Claim Form go to and click on Find a Form. n Call to obtain a form. 4. Complete the enrollee information and patient information sections of the claim form and sign the bottom. 5. Send the completed claim form and any related pharmacy receipt(s) to: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program P.O. Box Phoenix, AZ OVERSEAS you buy overseas must be equivalent to drugs that need a prescription in the United States. This is a U.S. federal law. File a claim for covered drugs and supplies you buy from pharmacies outside the United States and Puerto Rico. Use the following address to send both your: n Completed Retail Prescription Drug Overseas claim form n Itemized pharmacy receipts or bills Blue Cross and Blue Shield Service Benefit Plan, Retail Pharmacy Program P.O. Box Phoenix, AZ Or fax the information to: We provide translation and conversion services for your overseas claims. To get a claim form for your overseas prescription drug purchases: n Write to the above address use this address for any written questions about drugs you buy outside the United States and Puerto Rico. n Visit and click on Find a Form. n Call any time toll-free at SAVE TIME WITH OVERSEAS CLAIMS BY FILING ONLINE WITH MYBLUE For faster processing and payment, you can also submit overseas pharmacy claims online. It s easy. Just follow these simple steps: 1. Log in to MyBlue at 2. On the homepage, hover over the Health Tools tab and click Submit Overseas Claim. 3. Follow the instructions to submit the claim and upload your itemized bills. If you re new to MyBlue, register at org/signup. You ll need your member ID card and PIN to register. Call your local BCBS company to request a PIN during regular business hours, Monday through Friday. Once you have this information, complete all of the fields. After you log in, follow the steps above

16 FILING A CLAIM DRUGS FROM SUPPLEMENTARY PROVIDERS You may get prescription drugs and supplies from providers other than retail or mail pharmacies, like: n Your doctor n Your hospital 3. Include the itemized bill from the hospital with your claim to the Retail Pharmacy Program. CHARGES FOR PRESCRIPTION DRUGS AND COVERED SUPPLIES AS PART OF MEDICAL TREATMENT n A government health center In these cases, you need to pay for your items and file a claim form for reimbursement: 1. Be sure to get an itemized receipt. 2. Then, fill out the Health Benefits claim form. 3. Send your form, along with your itemized receipt, to your local Blue Cross and Blue Shield company. For drugs and supplies you get from these providers, your medical cost share amounts apply to covered charges. Check your 2016 Service Benefit Plan brochure (RI ) for details. HOSPITAL OUTPATIENT DEPARTMENTS Most hospital outpatient pharmacies are Non-preferred retail pharmacies. CHARGES ONLY FOR PRESCRIPTION DRUGS AND COVERED SUPPLIES If the outpatient hospital bill includes charges only for prescription drugs and covered supplies: 1. We will process the claim through the Retail Pharmacy Program. 2. Pay for your items and then file a Retail Pharmacy claim form. If the outpatient hospital bill includes charges for drugs or supplies as part of expenses for medical treatment: 1. Your local Blue Cross and Blue Shield company will process the claim. 2. Most hospitals will file these outpatient charges for you. 3. If the hospital does not file the claim for you, fill out a Health Benefits claim form. 4. Attach your itemized hospital bill, and send the claim to your local Blue Cross and Blue Shield company. For a copy of the claim form, visit and click on Find a Form

17 HOW TO CONTACT US Call these numbers for prescription drug information: RETAIL PROGRAM (Standard & Basic Option) Toll-free any time at MAIL SERVICE PROGRAM (Standard Option & Basic Option with Med B primary) Toll-free any time at OTHER BENEFIT OR CLAIMS INFORMATION Call your local Blue Cross and Blue Shield company. The customer service number is on the back of your Service Benefit Plan ID card. SPECIALTY PROGRAM (Standard & Basic Option) Toll-free at Monday-Friday: 7 a.m. to 9 p.m. (ET) Saturday/Sunday: 8 a.m. to 6:30 p.m. (ET) This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the Plan s Federal brochure, RI All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochure

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