Common Questions for Blue Advantage (PPO) Members
- When is the Annual Election Period (AEP)?
- Can I make changes outside of the Annual Election Period (AEP)?
- Why am I receiving my Annual Notice of Change (ANOC) packet so soon?
- Will I receive a new ID card annually?
- Can I keep my coverage if I move?
- If I qualify for Low Income Subsidy (LIS) this year, will I qualify again next year?
- What is Best Available Evidence (BAE)?
- Why do I have to pay an extra Part D amount because of my income? (Part D Income Related Monthly Adjustment Amount- IRMAA)
- What if I decide to change the way I pay my premium?
- How do I set up automatic monthly payments?
- How do I know if a provider is in the Blue Advantage network?
- How do I know if my prescription drugs are covered?
- My drug is not on your formulary. How can I get it added?
- What is the difference between a Preferred Cost-Sharing Pharmacy and a Standard Cost-Sharing Pharmacy?
- How do I file a paper claim for prescription drugs?
- Can I fill my prescription by mail?
- What are your Quality Assurance policies and procedures?
- What is the Medication Therapy Management (MTM) Program?
- What is Prime Therapeutics LLC?
The Annual Election Period allows you to make changes to your plan anytime between October 15 and December 7. Elections made during this time will be effective on January 1 of the following year. When Medicare has been notified of your election change, your membership with your previous MAPD and/or Part D plan will be cancelled effective December 31. To cancel coverage other than Medicare Advantage or Part D Plans, please contact your insurance carrier.
A new enrollee is allowed to make a one-time change during the Medicare Advantage Disenrollment Period (MADP), which takes place from January 1 to February 14. This period allows you to disenroll from a Medicare Advantage plan and return to your Original Medicare. You are not allowed to change from one Medicare Advantage plan to another Medicare Advantage plan or from one Part D plan to another Part D Plan.
You may also change plans anytime during the year if you qualify for a special election period, such as by qualifying for a Low Income Subsidy (LIS) or moving out of your plan's service area.
Medicare requires all Medicare Advantage and Prescription Drug plans to notify members of the upcoming year's changes by September 30 of each calendar year.
ID cards do not expire and will not be issued annually. If you need a new ID card, please contact Member Services at 1-888-234-8266.
Blue Advantage is only available to Alabama residents. Please note that failure to report an address change can result in the loss of your coverage.
If you move within the state of Alabama, you are still eligible to keep your Blue Advantage plan; however, premium and plan options may vary based on the county that you live in. Please contact our Member Services Department to advise of an address change and to determine if your move will constitute any changes to your plan.
If you move outside of Alabama, Medicare will allow you 60 days from the day you move to enroll in another Medicare Advantage or Part D plan that is located in your new state. If you are temporarily moving out of the coverage area, you are allowed to have a temporary address for up to 6 months. You are responsible for notifying us if your living status changes from a temporary to permanent residence or of any permanent changes to your physical address.
Please contact the Social Security Administration to see if you are required to reapply for Low Income Subsidy each year. There is no guarantee that you will automatically qualify each year, as the income criteria is subject to change. The Social Security Administration can be reached at 1-800-772-1213. If eligible for LIS, Social Security will send you a letter advising of your level of eligibility. Blue Cross and Blue Shield of Alabama will also be notified of any changes to your LIS eligibility.
If your modified adjusted gross income, as reported on your IRS tax return, is above a certain amount ($85,000 for individual, $170,000 for married couples), you will pay an extra amount in addition to your monthly plan premium. You may also hear this referred to as a surcharge, and can get more information on it here. If you have to pay an extra amount, the Social Security Administration (SSA) will send you a letter to advise what the extra amount is and how to pay it.
Depending on the payment method selected, it can take up to three months for your new payment method to take effect. In the meantime, you are responsible for making sure your plan premium is paid on time.
Call Member Services to set up by telephone. All payments are drafted on the first business day of each month.
Blue Advantage offers a large network of providers who are willing to serve you.
To see if an Alabama provider participates in the Blue Advantage network, you may:
- Visit our onlinedoctor finder
- Call the Member Services number on the back of your ID card
- Request that a Provider Directory for your county be mailed to you
Outside of Alabama, medical emergencies and visits to an Urgent Care Facility will process at an in-network benefit level, regardless of whether the provider is in the Blue Advantage network. For all other services outside of the coverage area, facility and provider participation may vary. To find out if an out-of-state facility or provider participates in the Blue Advantage network, contact Member Services.
To see if a specific drug is covered under Blue Advantage you may:
- View formularies online: Complete and Premier
- Call the Member Services number on the back of your ID card (non-members may call 1-888-543-9212)
- Request that a formulary be mailed to you
To request coverage for a medication not on the formulary, contact your physician and ask that a formulary exception request form be submitted on your behalf. This process can take up to 72 hours for a standard request. If your life, health or ability to regain maximum function may be at risk by waiting for a standard request decision, we will let you know our decision within 24 hours. This is considered an expedited request.
You may also contact Member Services at 1-888-234-8266, 8 a.m. to 8 p.m., seven (7) days a week. From February 15 to September 30, on weekends and holidays you may be required to leave a message. Calls will be returned the next business day. If a non-formulary medication is approved to be added to your formulary, the copay will process as a tier 4 non-preferred medication.
Preferred Cost-Sharing Pharmacies are pharmacies in our network where the Plan has negotiated lower cost-sharing for your covered drugs and also for your long-term supply of covered drugs. Standard Cost-Sharing Pharmacies are also network pharmacies; however, you will pay a higher copay for your covered drugs and full price for a long-term supply of covered drugs. Both are network pharmacies and have a lower drug price than Out-of-Network Pharmacies.
Only Mail Order and Preferred Cost-Sharing Pharmacies can offer the lower copayments for a 90-day supply of approved drugs. Standard Cost-Sharing Pharmacies do not offer lower copayments for a 90-day supply of prescription drugs. Standard Cost-Sharing, Preferred Cost-Sharing and Mail Order Pharmacies can be found in the2016 Pharmacy Directory.
Send your request for payment, along with receipts documenting the amount paid, to:
Part D Claims
PO Box 14429
Lexington, KY 40512-4429
Yes, we offer the convenience of having your medications purchased through our mail order programs with Prime Mail and Walgreens. The benefits of using mail order include:
- Saves Money by getting a 90-day supply for only 2 copays with free shipping
- Saves Time since it's delivered to your home and no refills are needed for several months
- Offers Convenience: You can order refills online, by mail or by phone
There are several ways to enroll in mail order. To register for these services please call or visit the websites below:
Prime Mail Website
TTY: 711, 24 hours a day, 7 days a week
TTY: 1-800-573-1833, 24 hours a day, 7 days a week
Blue Cross and Blue Shield of Alabama offers a number of standard Drug Utilization Management (DUM) services such as formulary management, prior authorization, quantity limits and step-therapy. These programs encourage safe, appropriate and cost-effective use of drugs. The goal of DUM is to monitor and prevent over- and under-utilization of prescription drugs while respecting the physician's prescribing authority. Using DUM, we also track and trend utilization, identify opportunities for improvement, and document and implement corrective actions when necessary. All policies are reviewed quarterly by an independent committee of pharmacists and physicians.
The MTM Program is a free service offered by your plan that can help you keep your medications on the right track. Click here to learn more about the MTM Program.
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Prime Therapeutics is an independent company providing pharmacy benefit management services for Blue Cross and Blue Shield of Alabama Blue Advantage (PPO) members.