Medicare Part D and Medicaid Drugs

When you join our plan, if you are taking any prescription or over-the-counter drugs that Blue Cross Community MMAI (Medicare-Medicaid Plan)SM does not normally cover, you can get a temporary supply. We will help you get another drug or get an exception for Blue Cross Community MMAI to cover your drug, if medically necessary.

Coverage Determination

If your doctor or pharmacist tells you that we will not cover a prescription drug you should contact us and ask for a coverage determination.

If you request an exception, your doctor must provide a statement to support your request To learn more about coverage determination, see Chapter 9 of the Member Handbook on the Forms and Documents page.

Request for Medicare Prescription Drug Coverage Determination

Request for Redetermination of Medicare Prescription Drug Denial

Your doctor can submit these forms using MyPrime or CoverMyMeds®.

For assistance, Contact Us.

Appeal

If we do not accept your coverage determination, you may want to ask for an appeal. If you want to appeal, you must request it within 60 days after the date that your coverage determination is denied.

You, your doctor, or your representative may request an appeal. You can name a relative, friend, attorney, doctor or someone else to be your representative.

Appointment of Representative

You can Contact Us to learn how to appoint a representative.

File a Grievance

A grievance is a complaint about any matter besides a service that has been denied, reduced or ended. It is different from a coverage determination because it usually does not involve coverage or payment for prescription drugs.

If you have a grievance, we encourage you to Contact Us. You may also contact Medicare by using the online form at www.medicare.gov.

Information on how to obtain aggregate number of grievances, appeals, and exceptions can be requested by phone, written mail requests or by fax.

Member Services: 1-877-723-7702 (TTY 711)

Mailing Address:
Blue Cross Community MMAI
Appeals and Grievances
P.O. Box 27838
Albuquerque, NM 87125-9705

Fax: 1-866-643-7069

General Information Questions

Additional information about your benefits can be requested by phone, written mail requests or by fax.

Member Services: 1-877-723-7702 (TTY 711)

Mailing Address:
Blue Cross Community MMAI
Medicare Part D General Information
P. O. Box 3836
Scranton, PA 18505

Fax: 1-855-674-9193

MyPrime.com is a pharmacy benefit website owned and operated by Prime Therapeutics LLC, a separate company providing pharmacy benefit management services for your plan.