2021 Prescription Drug Information
Our Medicare Advantage plans are offered with or without a prescription drug benefit. Click on the Medicare Formulary to see which drugs are covered by the plan.
- Click on the Notice of Formulary Change section to see a summary of the month-to-month formulary changes including additions and deletions.
- Click on the Low Income Subsidy/ Extra Help From Medicare section to find out if you may qualify for extra help to pay for your prescription drug costs.
- The New York State EPIC Program section has a link directly to the NYS Website where you can learn if you qualify for additional help lowering your prescription drug costs.
The 2021 Medicare Formulary includes a list of prescription care drugs covered by a prescription drug plan.
Updated December 1, 2021
Notice of Formulary Change
Find a Pharmacy
With over 63,000 pharmacies serving our members locally and nationally, our pharmacy network meets the pharmacy access requirements as mandated by the Centers for Medicare and Medicaid Services (CMS).
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if 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 supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with at least a 91 day transition supply, consistent with dispensing increment, (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 are in a long-term care facility and need a drug that is not on our formulary or if 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.
If a member submits a prescription for a transition eligible drug and it is rejected at Point of Sale, a message will be relayed to the pharmacist to call for additional instructions if the member underwent a recent level of care change. After confirming the member had a level of care change, the pharmacist will be instructed to enter a series of override codes to allow the member to receive a one-time transition supply of his or her prescription. At that time, all transition supply procedures will apply including member notifications for transition supply fills.
Out of Network Prescription Drug Coverage
We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are two instances when we would cover prescriptions filled at an out-of-network pharmacy:
- There are no network pharmacies within a reasonable driving distance that provide 24 hour service.
- You need to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).
In situations like these, please check first with Pharmacy Services to see if there is a network pharmacy nearby. You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.
Our number: 1-833-735-4512 TTY/TDD: 711
October 1 - March 31: 8 a.m. - 8 p.m., 7 days a week
April 1 - September 30: 8 a.m. - 8 p.m., Monday - Friday
Drug Prior Authorization Requirements
Medicare Pharmacy Quantity Limits
Quantity Limit amounts and days for prescriptions for Medicare Members.
Updated December 1, 2021
Step Therapy Guidelines
Medication Therapy Management
Services or programs that optimize therapeutic outcomes for individuals through improved medication use. These programs are not considered a benefit. Please contact customer service for additional information.
Low-Income Subsidy / Extra Help from Medicare
You might qualify to get help in paying for your drugs. “Extra Help” from Medicare, also called the “low-income subsidy” or LIS.
Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs:
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.
This table shows you what your monthly plan premium will be if you get extra help.
|Your Level of Help||Freedom Value (HMO)||Freedom Plus (HMO)||Forever Premier (PPO)||Senior 652 (HMO)||Freedom Nation (PPO)||Forever Blue 770 (HMO)|
*This does not include any Medicare Part B premium you may have to pay.
The Highmark Blue Shield of Northeastern New York Medicare Advantage plan premiums listed above include coverage for both medical services and prescription drug coverage.
Refer to your Evidence of Coverage – LIS Rider for detailed information, including your exact premium amount and prescription drug copays. If you get your coverage through your former employer, please contact the benefits administrator for your premium amount.
If you aren't getting extra help, you can see if you qualify by calling:
New York State's EPIC Program
EPIC (Elderly Pharmaceutical Insurance Coverage) is a program offered by New York State that helps seniors pay for prescription drugs. EPIC can help lower Medicare Part D drug costs by helping pay for drugs in the coverage gap, as well as providing assistance with Part D premiums, if eligible.
Best Available Evidence
Review this information if you believe you may qualify for 'extra help' with your Medicare Prescription Drug Plan costs, but your plan's system and CMS's systems do not reflect your eligibility for this help. Find out how you may be able to obtain your prescriptions at the correct Low Income Subsidy (LIS) cost sharing level if you can show evidence of your LIS eligibility.
Request for Redetermination of Medicare Part D Prescription Drug Denial
If Blue Shield of Northeastern NY denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.
Coverage Determination Form
Highmark Blue Shield of Northeastern New York (Highmark BSNENY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark BSNENY is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. Highmark BSNENY complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-833-735-4515 (TTY 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-833-735-4515 (TTY 711).
Content last updated: December 1, 2021