IC Blue Questions and Answers
General
1. I just received notice of a prescription drug plan for my nongroup coverage. Can you explain how the plan works?
The pharmacy benefit structure is as follows:
- 50 percent copayment with a $10 minimum and $100 maximum.
- $2500 per member annual benefit maximum.
- Once BCBSM has paid $2,500 in benefits in a calendar year for a member, the member may continue to fill prescriptions at network pharmacies and will pay the BCBSM-negotiated rate for prescriptions. This rate may be lower than the rate charged to pharmacy customers not enrolled with IC Blue.
2. How much are the monthly rates?
Click here for the table of monthly rates.
3. What happens if I'm late with my premium payment?
If payment is not made by the date indicated on your bill, your coverage will not be in effect and your doctor, hospital or pharmacy will be advised that your coverage is not active.
4. What's Medco Health? I thought my insurance was with BCBSM?
Blue Cross Blue Shield of Michigan, along with Medco Health, manages your prescription drug benefit. Your insurance is still handled through BCBSM. However, Medco Health processes your pharmacy claims as well as helps manage other aspects of your pharmacy benefit. For example, Medco Health helps ensure that your prescriptions are checked for potential drug interactions.
5. Do I need a new prescription from my doctor to use my new card?
No. You will be able to receive refills of your current prescription using your new card at participating retail pharmacies. However, you should present your new I.D. card to the pharmacy and expect to pay your appropriate retail copayment. The participating retail pharmacy will send a claim to Medco Health for the prescription.
6. What does it mean to be age rated?
Age rating means that we will base your premiums on your age.
7. As the premium rates are determined by age, will the rates be based on me, my spouse or my dependents?
Rates are based on the individual applying as the contract subscriber. Since dependents are defined as the spouse and children by blood, marriage, guardianship and adoption, the contract must be based on the head of household.
8. On my next birthday I will be eligible for the next band of age rating. When will my rates change?
The rates are quoted on the age of the subscriber at the time of enrollment. The rates will change as the subscriber's age increases to a new age band. This rate change will occur on the first billing cycle after the subscriber's date of birth, when the subscriber's age exceeds the age in the current age band.
9. Can I cancel my coverage and reapply under my spouse?
Yes, you may cancel your coverage age at any time. However, you may have a lapse in coverage and you may also be subject to the 180-day pre-existing condition waiting period. Also note that the prescription drug maximum is based on the annual payment by BCBSM for each member on the contract. That maximum will be carried for each member, even if the member has transferred to a different contract. If you cancel your coverage under I.C. Blue, you must wait one year from the cancellation date to reapply.
10. Is my annual prescription drug benefit maximum of $2,500 based on all members on my contract, or is it $2,500 per member?
The annual prescription drug benefit maximum is $2,500 per member, not $2,500 per contract. If a member transfers to another contract, the calculation of the annual benefit used by that member will transfer as well.
11. What happens when I meet my annual prescription drug benefit maximum? Will any other form of prescription coverage be available?
Once you meet your annual prescription drug maximum, you will be eligible to continue purchasing prescription drugs at your existing pharmacy under the Individual Care Blue certificate and will pay the Blue Cross Blue Shield of Michigan negotiated rate. This rate may be lower than the rate charged to pharmacy customers not enrolled with IC Blue.
12. Will I get a discount every time I go to the pharmacy?
No. Sometimes the pharmacy may already offer a savings for a particular drug that may be better than the savings offered through your plan. Occasionally, the amount Blue Cross Blue Shield of Michigan pays pharmacies is the same amount you would normally pay for certain drugs, so no savings would apply.
13. When will my annual prescription drug benefit maximum start over?
You $2,500 annual prescription maximum will start over each January 1 as long as your premiums are paid up to date.
14. Why are you asking for money with my application?
Payment with your application allows Blue Cross Blue Shield of Michigan to process your application, activate your coverage and issue an I.D. card promptly without having to bill you and wait for payment.
15. Why do I have to make a two-month payment?
Individual contracts are billed on a bimonthly basis. You will receive one bill every two months.
16. What happens if my application is rejected?
If your application is rejected, we will provide the reason to you in writing and return any money you've paid.
17. What drugs are covered under the program?
"Rx only" drugs (drugs that require a prescription to be dispensed), state controlled drugs and insulin.
18. Are compound prescriptions covered?
Yes, if the prescription contains at least one "Rx only" drug ingredient and the compound is FDA approved for the treatment of your medical condition (i.e., it meets all of the requirements outlined in the certificate), it will be covered. Your copayment liability and other terms of your contract would apply.
There are two ways to submit claims for compound medications:
- The easiest way is to have the participating retail pharmacy submit the claim to Medco Health electronically. This way, you will pay your co-payment at the time of service. Medco Health will reimburse the pharmacy based upon your plan's contracted rate.
- You may also submit a direct claim to Medco Health. This is necessary anytime you pay the entire cost of the medication, whether it is at a participating or a nonparticipating retail pharmacy. Please understand that if you submit a direct claim, you will be responsible for any cost differences between what the pharmacy charges and what your plan allows for reimbursement.
In order for your direct claim to be processed, you must include the itemized list of ingredients along with your receipt and fully completed claim form. Ask your pharmacist for this list when you fill your prescription. Please be sure it includes:
- The amount charged by the pharmacy.
- The total volume or quantity of the compound (such as the number of capsules or the number of milligrams).
- The valid National Drug Code (NDC) for each ingredient.
- For each NDC number, include the quantity of that ingredient.
19. Can I get my prescription through the mail?
No. This program does not include mail order prescription drug coverage.
20. Are contraceptive medications covered?
Yes, all "Rx only" contraceptive medication is covered with the exception of contraceptive implants.
21. Can I get infertility, impotence, smoking cessation or weight loss products under this coverage?
Yes, infertility, impotence, weight loss and smoking cessation drugs are covered under this program.
22. Do I have prescription coverage outside of Michigan?
Yes. However, to receive full benefits, you must go to a Medco Health participating pharmacy outside of Michigan. You can locate a Medco Health participating pharmacy by visiting the Medco Health Web site and click on the link "find a local pharmacy" or by contacting BCBSM customer service. If you go to a nonparticipating pharmacy, claims will be reimbursed at 75 percent of the approved amount, minus the copayment. You will be responsible for any additional charges between the amount charged by the pharmacy and BCBSM's approved amount.
23. Do I have prescription coverage outside of the country?
The following applies to prescriptions filled outside of the country:
- If the member lives in Michigan and travels to another country to purchase drugs, the out-of-network sanction is applied and claims will be reimbursed at 75 percent of the approved amount, minus the copayment.
- If the member lives in Michigan and travels to another country and requires prescription drugs due to an emergency, the claim will be reimbursed at 100 percent of the approved amount, minus the copayment.
- If the member temporarily lives in another country, the claim is reimbursed at 100 percent of the approved amount, minus the copayment.
24. Can I get this coverage if I live in Canada?
You must live in Michigan to receive this coverage.
25. What if the pharmacy is not participating?
You will have to pay for the prescription and submit the pharmacy receipt and completed direct claim form to Medco Health for reimbursement. Because the pharmacy is not participating, you will have to pay a sanction of 25 percent of the approved amount. However, emergency services will be reimbursed at 100 percent of the approved amount, minus your copayment.
Pharmacy receipts must contain the following information:
- Date prescription filled
- Name and address of pharmacy
- Doctor name or ID number
- NDC number (drug number)
- Name of drug and strength
- Quantity and days' supply
- Prescription number (Rx number)
- DAW (Dispense As Written)
- Amount paid
(Refer to compound medication question and answer for additional information required to submit direct claims for compound medications.)
26. Can I get more than a 34-day supply of my medication at retail?
Vacation overrides can be granted for a maximum of a three-month supply; they cannot exceed the paid to date of the contract; and they can be performed once per calendar year.
Benefit Maximum
1. Do I have a deductible?
No, this program does not include a deductible for medical / surgical or prescription drugs.
2. Please explain how the prescription drug benefit maximum works.
With IC Blue, a member pays a 50 percent copayment and BCBSM pays the other 50 percent for each prescription. BCBSM's payments accumulate toward a $2,500 prescription drug benefit maximum per member per calendar year. In other words, once BCBSM's payments reach $2,500, the prescription drug benefit for that member is exhausted and the member is responsible for 100 percent of the BCBSM-approved amount for each prescription thereafter.
3. I received a letter regarding my prescription drug benefit maximum from BCBSM. What does it mean?
This letter is sent by BCBSM as a courtesy to keep you updated on the status of your prescription drug benefit maximum. You will receive a reminder letter when you reach $1800 of your maximum and again when you reach the total $2500 maximum.
4. Can I carry over any unused portion of the prescription drug benefit maximum toward subsequent years?
No. You will start a new prescription drug benefit maximum at the beginning of each calendar year.
Copayments
1. What is my copayment for prescriptions?
Your copayment is 50 percent of the amount BCBSM has agreed to pay for the drug. The minimum copayment is $10; the maximum copayment is $100.
2. How will copayments be calculated under this plan?
Prescription copayments will be calculated as follows:
- If the approved amount for the prescription is $7.50, the member will be responsible for a $7.50 copayment.
- If the approved amount for the prescription is $18.00, the member will be responsible for $10.00 since 50 percent of the approved amount is less than the $10.00 copay minimum.
- If the approved amount for the prescription is $30.00, the member will be responsible for $15.00 since 50 percent of the drug approved amount is $15.00 and this amount falls between the $10.00 minimum and $100.00 maximum.
- If the approved amount for the prescription is $300.00, the member will be responsible for $100.00 since 50 percent of $300.00 = $150.00, which exceeds the $100.00 maximum.
3. What happens if my benefit maximum is reached half way through a claim payment?
This is best answered using an example:
- The member has $50 remaining on their benefit maximum (has met $2,450)
- The approved amount for the drug is $150
- BCBSM pays $50, reaching the member's $2,500 maximum
- Member pays $75 copayment (50 percent of $150), plus $25 (the amount remaining of what would have been BCBSM's obligation if the benefit maximum hadn't been reached)
- Member pays: $100
Brand/Generic Drugs
1. Can I get the brand name drug?
You can get the brand name drug, but if your physician did not write "Dispense as Written" on the prescription, you will be responsible for your copayment, plus the difference in cost between the brand name and generic drug.
2. What's the difference between a brand name and generic drug?
The brand name of a drug is the product name under which the drug is advertised and sold. Many product brands have become household names through advertising. Generic drugs, on the other hand, have no public image. However, generic equivalent drugs have the same active ingredients and are subject to the same rigid U.S. Food and Drug Administration standards for quality, strength and purity as their brand name counterparts. Access the following link for additional information on generic drugs: www.theunadvertisedbrand.com.
3. Will my copayment be less if I use a generic drug?
Since generic drugs generally cost less than brand name drugs, your copayment percentage should be less, too.
4. Is my pharmacy participating in this program?
As long as you are going to a Preferred Rx pharmacy in Michigan or a Medco Health pharmacy for services outside of Michigan, your claims will be paid according to your Individual Care Blue benefit plan. Most Michigan pharmacies participate in the Preferred Rx Program.
Formulary
1. What is a formulary?
A formulary is a preferred list of high quality, cost-effective medications. Blue Cross Blue Shield of Michigan encourages doctors to prescribe from this list.
2. Are there different types of formularies?
Yes. Formularies can be classified as being either "open" or "closed." Open formularies are administered such that both formulary and nonformulary products may have some coverage under the Plan's prescription drug program. Closed formularies are administered such that drugs which are not part of the formulary are not covered under the Plan's prescription drug program. BCBSM uses the open formulary design.
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