2024 Formulary (drug list)

The formulary, also known as a drug list, for each Blue MedicareRx plan includes most eligible generic and brand-name drugs. All the drugs we cover are carefully selected to provide the greatest value while meeting the needs of our members. Drugs on the formulary are organized by tiers. Generally, a drug on a lower tier will cost less than a drug on a higher tier. If you’re interested in saving money on your prescriptions, discuss with your doctor whether switching to a similar drug on a lower tier might work for you. Important Information About Vaccines and Insulin
Blue MedicareRx covers most Part D vaccines at no cost to you (and for our Value Plus plan, even if you haven't paid your deductible).

You won't pay more than $35 for a one-month supply of each insulin product covered by Blue MedicareRx, no matter what cost-sharing tier it's on (and for our Value Plus plan, even if you haven't paid your deductible)

Formulary tiers

Tier	Description
Tier 1	Certain generic drugs that are available at the lowest copayment for our members
Tier 2	Higher cost generic drugs available at a higher copayment than Tier 1 generic drugs
Tier 3	Common brand-name and some higher cost generic drugs
Tier 4	High cost generic and non-preferred drugs, many of which may have lower cost options available on Tier 1, 2 or 3
Tier 5	Unique and/or very high-cost brand and some generic drugs of which you pay a percentage of the drug cost; some may require special handling and/or close monitoring

Tier assignments vary by plan. Use the Drug Pricing Tool to price the medications you are currently taking and see which Blue MedicareRx plan is best for you.

Formulary updates

Blue MedicareRx formularies may change during a calendar year if we remove a drug, change a drug’s tier, or add a special coverage requirement. If a change affects a drug you take, we will notify you at least 60 days in advance, as required by Medicare. Sometimes, we must remove a drug immediately for safety reasons or due to its discontinuation by the manufacturer. If a sudden removal occurs, we will notify our affected members as soon as possible. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. We may not tell you in advance before we make that change-even if you are currently taking the brand name drug. View the upcoming formulary changes for Blue MedicareRx (PDP) Value Plus (PDF) and Blue MedicareRx (PDP) Premier (PDF).

Formulary coverage requests

Prior authorization – you will need to obtain approval before you fill your prescription
Quantity limit – There is a limit to the amount of the drug the plan will cover with each prescription filled
Step therapy – You may be required to try an alternative drug before this drug is covered
Limited access – This prescription may be available only at certain pharmacies

If you believe your use of a drug meets all special requirements, or that you should be exempt from a requirement, you and/or your doctor must request a coverage determination before the plan will cover your drug. You can also request that the plan cover a drug that is not included in the formulary.

Drugs not covered under Medicare

There are certain types of drugs that Blue MedicareRx cannot include in the formulary due to federal law, including:

Non-prescription drugs (also called over-the-counter drugs).
Drugs for treatment of anorexia, weight loss or weight gain.
Drugs to promote fertility.
Drugs for cosmetic purposes or hair growth.
Drugs to relieve a cough or cold symptoms.
Prescription vitamins and minerals (except for prenatal vitamins and fluoride preparations).
Drugs for treatment of sexual or erectile dysfunction (ED).

In addition, a Medicare Part D plan cannot cover:

Drugs that would be covered under Medicare Part A or Part B.
Drugs not approved by the U.S. Food and Drug Administration (FDA).
Off-label drug use, which means using a drug for treatments not specifically mentioned on the drug’s label.

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare contract. Blue MedicareRx Value Plus (PDP) and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to service residents of Connecticut, Massachusetts, Rhode Island, and Vermont.

Coverage is available to residents of the service area or members of an employer or union group and separately issued by one of the following plans: Anthem Blue Cross ® and Blue Shield ® of Connecticut, Blue Cross Blue Shield of Massachusetts, Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

S2893_2309 Page Last Updated 10/01/2023.

CVS Caremark is an independent company that has been contracted to administer pharmacy benefits and provide certain pharmacy services for Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont who are the legal entities which have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx (PDP) plans.

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are Independent Licensees of the Blue Cross and Blue Shield Association®, SM, TM Registered and Service Marks and Trademarks are property of their respective owners. ® , SM, TM Registered and Service Marks and Trademarks are property of their respective owners.
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