This plan uses a prescription drug formulary.1  Benefits are limited to the drugs on this formulary unless an exception is approved by the plan

Drugs that are excluded include:

• Agents when used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose such as morbid obesity)
• Agents when used to promote fertility
• Agents when used for cosmetic purposes or hair growth
• Agents when used for the symptomatic relief of cough and colds
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
• Non-prescription drugs
• Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee
• Agents when used for the treatment of sexual or erectile dysfunction

• Certain drugs have quantity limits.
• Certain drugs require prior authorization.
• Certain drugs require step therapy.
• Drugs covered by Medicare Part B are not payable as Part D benefits. (Refer to your Medicare Part B coverage documents for Part B drug coverage.)
• Compounded medications require an exception request to be approved.
• Members must use network pharmacies to receive full benefits.
• Drug benefits or services not described in the plan formulary or the Evidence of Coverage, or not required by law or regulations, are not covered.
• Prescriptions filled by pharmacies outside the United States, even for a medical emergency are not covered.
• Replacement of lost or stolen prescriptions are not covered.
• Prescriptions filled prior to effective date of coverage or after disenrollment date are not covered.
• Enhanced coverage gap drug benefits - In the coverage gap, you pay a copayment for Tier 1 preferred generics and 25% coinsurance for all other generics.
• Standard coverage gap drug benefits - In the coverage gap, you pay 25% coinsurance for all drugs (brand or generic).
• Medications cannot be refilled before 75% of the time period for the supply has passed. For example, if the prescription is written for a 30-day supply, then you may obtain a refill beginning on the 23rd day.
• An exception request for a Tier 5 (Specialty Tier) drug to be paid at the lower cost-sharing level is not permissible under this plan.
• In order to enroll in Blue Medicare Rx, you must reside within North Carolina. If you are in prison, you cannot join this plan.
• After the initial enrollment period, you may not be able to switch plans until the next open enrollment period.
• If you are eligible for Part D, and don't sign up in your initial enrollment period, you may have to pay more if you sign up later, due to a Medicare late enrollment penalty.
• The plan's contract may be canceled by either the plan or the Centers for Medicare & Medicaid Services.
• Members enrolled under this plan may not have drug coverage through both a Medicare Part D prescription drug plan and a Medicare supplemental plan.
• Plan benefits and premium are subject to change annually.
• All claims must be received within 3 years of the fill date. For example, if a drug is purchased on January 31, 2019, the claim must be received no later than January 31, 2022. Claims received after this time frame will not be eligible for coverage.

• 1Formulary and pharmacy network may change at any time. You will receive notice when necessary.