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Forms and Information
Medicare Advantage/BlueMedicare Rx

Drug Claims & Alternatives
Requesting a Formulary Exception

What if your drug is not on the formulary?
If your prescription is not listed on the formulary, you should first contact BCBSAZ Member Services to see if it is covered. If it is not covered, you have three options:

  1. You can ask your doctor if you can switch to a drug that is already on the formulary.
  2. You can ask us to make an exception and cover your drug.
  3. You can pay out of pocket for the drug and request the plan reimburse you by submitting an exception request.

How can you request an exception to the formulary?
You can ask us to make an exception to our coverage rules using the Request for Medicare Prescription Coverage Determination. In order for us to make a decision, your doctor must include supporting medical information. Have your doctor fax the exception request and supporting statement to our contracted pharmacy benefit manager, MedImpact, at 1-858-790-7100, TTY: 711.

Request a Formulary Exception Online

Medicare Transition Policy
Transitioning to and from our Medicare plan

New Members
As a new member in our plan, you may currently be taking drugs that are not on our formulary or taking drugs that are on our formulary in a limited basis. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our formulary.

If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you may be eligible to receive an initial 30-day transition supply of the drug anytime during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request a formulary exception.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Continuing Members
As a continuing member in the plan, you will receive your formulary (with a clickable link). You may notice that a formulary medication, which you are currently taking, is either not on the upcoming year’s formulary or its cost sharing or coverage is limited in the upcoming year.

In this case, you must work with your doctor to either find an appropriate alternative therapy on our new formulary or request a formulary exception prior to the beginning of the new year. If the exception request is approved, we will authorize payment.

For BCBSAZ members that move from one level of care to another as described below, BCBSAZ will provide a temporary, one-time up to 30-day supply of a Part D eligible non-formulary medication. This one-time, fill needs to be authorized through the exception process. Therefore, your doctor or pharmacist will need to let MedImpact (at 1-800-788-2949) know that you are moving from one level of care to another.

Examples of moving (or transitioning) from one level of care to another include the following:

  1. Members transitioning from hospital to home (discharge medications)
  2. Members transitioning from a Skilled Nursing benefit (LTCF) and reverting to the Part D benefit
  3. Members terminating a Hospice election and reverting to Part A and Part D benefit
  4. Members discharged from a Chronic Psychiatric Hospital to home (discharge medications)

If you have any questions about our transition policy or need help asking for a formulary exception, call BCBSAZ.

Blue Cross® Blue Shield® of Arizona (BCBSAZ) is contracted with Medicare to offer HMO and PPO Medicare Advantage plans and PDP plans. Enrollment in BCBSAZ plans depends on contract renewal.

BCBSAZ offers BluePathway HMO and BlueJourney PPO Medicare Advantage plans. BCBSAZ Advantage, a separate but wholly owned subsidiary of BCBSAZ, offers Blue Medicare Advantage Standard, Classic, and Plus HMO plans.

You are eligible to enroll in a BCBSAZ Medicare Supplement plan if you are age 65 or older, entitled to Medicare Part A, and enrolled in Medicare Part B, and you live in the plan service area. You must continue to pay your Medicare Part B premiums (and Part A, if applicable), if not otherwise paid for by Medicaid or another third party. During the first six months when you are age 65 and also enrolled in Medicare Parts A & B you cannot be denied a Medicare Supplement plan when you apply for one, regardless of health status.

Health Choice Pathway HMO D-SNP is a Health Plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in Health Choice Pathway HMO D-SNP depends on contract renewal. Health Choice Pathway Member Services can be reached at 1-800-656-8991, TTY: 711, 8 a.m. to 8 p.m., 7 days a week.

Blue Cross Blue Shield of Arizona (BCBSAZ) and Health Choice Arizona (HCA) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We provide free aids and services to people with disabilities to communicate effectively with us, such as qualified interpreters and written information in other formats such as large print and accessible electronic formats. We also provide free language services to people whose primary language is not English, such as qualified interpreters and written information in other languages. If you need these services call 1-800-446-8331 (TTY: 711) for BCBSAZ Medicare Advantage or 1-833-229-3593 (TTY: 711) for BCBSAZ Blue MedicareRx (PDP) or 1-800-656-8991 (TTY: 711) for HCA.

Member Services can be reached at 480-937-0409 (in Arizona) or at our toll-free phone number at 1-800-446-8331 (TTY users should call 711). Hours are 8 a.m. to 8 p.m., Monday through Friday from April 1 to September 30; and 7 days a week from October 1 to March 31. Member Services also has free language interpreter services available for non-English speakers.

Birdi, Inc. Part D Services is an independent company providing prescription mail order services.

Spanish (BCBSAZ): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-446-8331 (TTY: 711).

Navajo (BCBSAZ): Díí baa akó nínízin: Díí saad bee yάnílti’ go Diné Bizaad, saad bee άkά’ άnída’ άwo’ dę͗ę͗, t’άά jiik’eh, éí nά hóló̖, kojí̖ hódíílnih 1-800-446-8331 (TTY: 711).

Spanish (HCA): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-656-8991 (TTY: 711).

Navajo (HCA): Díí baa akó nínízin: Díí saad bee yάnílti’ go Diné Bizaad, saad bee άkά’ άnída’ άwo’ dę͗ę͗, t’άά jiik’eh, éí nά hóló̖, kojí̖ hódíílnih 1-800-656-8991 (TTY: 711).

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Last Updated 04/10/2022