When you go to an in-network pharmacy, the pharmacy automatically submits your claim to us. However, if you have to go to an out-of network pharmacy because of one of the reasons listed below, the pharmacy may not be able to submit your claim directly to us.
If you are traveling outside your service area (within the United States) and run out of your medication, lose your medication, or become ill, and you cannot access a network pharmacy.
If you are unable to obtain a covered drug in a timely manner because there is no network pharmacy within a reasonable driving distance that provides 24-hour service.
If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail order pharmacy.
If you receive a Part D drug, dispensed by an out-of-network institutional-based pharmacy, while you are a patient in the emergency department, provider-based clinic, outpatient surgery or other outpatient setting.
If you have received your prescription during a State or Federal disaster declaration or other public health emergency declaration in which you are evacuated or otherwise displaced from your service area or place of residence and can not be reasonably expected to obtain covered Part D drugs at a network pharmacy.
In these situations, please check first with Member Services to see if there is a network pharmacy nearby. However, if you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost by sending us your request for payment, along with your receipt documenting the payment you have made.
To make sure you are giving us all the information we need to make a decision, you can fill out our claim form to make your request for payment. To obtain a claim form, download the PDF form for the plan you are enrolled in or call Member Services and ask for the form.
Mail your request for payment together with any receipts to us at this address:
BCBSM Part D Claims Department
c/o Medco Health Solutions, Inc.
P.O Box 14718
Lexington, KY 40512
Note: If you need to submit a claim for prescription drugs you received in 2009, please use the 2009 Medicare Plus Blue PFFS (PDF 49K) or 2009 Prescription Blue PDP (PDF 47K) claim form and return it to the address listed on the form.
Medical claims
Most of the time, doctors, hospitals and other health care providers submit claims directly to us. Occasionally, you may need to pay for a service out-of-pocket and seek reimbursement from us.
Member reimbursement form
This form is also called Member Application for Payment Consideration. You should use this form if you've received covered medical services and are seeking reimbursement from us. This is most often used for flu shots.
When we receive your request for payment, we will let you know if we need any additional information. Otherwise, we will consider your request and decide whether to pay it and how much we owe. Contact us for more information if you have any other questions.
Medicare Plus Blue PPOSM and Medicare Plus Blue PFFSSM are health plans with Medicare contracts. Prescription Blue PDPSM is a stand-alone prescription drug plan with a Medicare contract.
Medicare Plus Blue PPOSM Medicare Plus Blue PPOSM is available to all Medicare beneficiaries who are Michigan residents who reside within the plan's 75-county service area and are entitled to receive services under Medicare Part A and enrolled in Part B.
Medicare Plus Blue PPOSM is available in these counties: Alcona, Alger, Allegan, Alpena, Arenac, Baraga, Barry, Bay, Berrien, Branch, Calhoun, Cass, Chippewa, Clare, Clinton, Crawford, Delta, Dickinson, Eaton, Genesee, Gladwin, Gogebic, Gratiot, Hillsdale, Houghton, Huron, Ingham, Ionia, Iosco, Iron, Isabella, Jackson, Kalamazoo, Kent, Keweenaw, Lake, Lapeer, Lenawee, Livingston, Luce, Mackinac, Macomb, Manistee, Marquette, Mason, Mecosta, Menominee, Midland, Missaukee, Monroe, Montcalm, Montmorency, Muskegon, Newaygo, Oakland, Oceana, Ogemaw, Ontonagon, Osceola, Oscoda, Otsego, Ottawa, Presque Isle, Roscommon, Saginaw, Sanilac, Schoolcraft, Shiawassee, St. Clair, St. Joseph, Tuscola, Van Buren, Washtenaw, Wayne, Wexford.
With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare allowed amount and the contracted amount is lower. You may receive services from any provider who accepts your Medicare Plus Blue PPOSM ID card. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit bcbsm.com/medicare/search.shtml.
Medicare Plus Blue PPOSM provides reimbursement for all covered benefits regardless of whether they are received in-network, as long as they are medically necessary.
Medicare Plus Blue PFFSSM Medicare Plus Blue PFFSSM is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and enrolled in Part B.
A Medicare Advantage private fee-for-service plan works differently than a Medicare supplement plan. Your doctor or hospital can continue to treat you if it agrees to accept our terms and conditions of payment, and thus may choose not to treat you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may choose not to provide health care services to you, except in emergencies. Providers can find the plan's terms and conditions on our Web site at bcbsm.com/ma. You can also read more about how private fee-for-service plans work for you in our downloadable flyer (PDF 160K).
Prescription Blue PDPSM Prescription Blue PDPSM is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B.
Medicare beneficiaries enrolled in a Medicare Advantage PFFS plan that includes Medicare prescription drugs or any Medicare Advantage coordinated care (HMO or PPO) plan will be automatically disenrolled from the HMO, PPO or Medicare Advantage PFFS plan if they enroll in a prescription drug plan; and Medicare beneficiaries enrolled in a private fee-for-service plan (PFFS) that does not include Medicare prescription drug coverage, a Medicare Advantage Medicare Savings Account (MSA) plan or an 1876 Cost plan may enroll in a prescription drug plan and will not be automatically disenrolled from the PFFS, MSA or 1876 Cost plan.
Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM and Prescription Blue PDPSM
Premiums vary by county. You must continue to pay your Medicare Part B premium.
In Michigan, 86 percent of pharmacies are network pharmacies; nationwide, more than 80 percent of pharmacies are in the network, including the majority of chain pharmacies, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies (Source: 2010 Pharmacy Directory). In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Customer Service at 1-877-469-2583, 8 a.m. to 8 p.m., seven days a week. TTY users should call 1-800-481-8704. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X435, Detroit, MI 48226.
If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.
The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information contact the plan Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1, 2011. Please contact Blue Cross Blue Shield of Michigan for details.
In addition to enrolling through this Web site, Medicare beneficiaries may enroll in Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM or Prescription Blue PDPSM through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at medicare.gov. For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. You may only enroll in Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM or Prescription Blue PDPSM during specific times of the year. To learn more about enrollment periods, please contact Customer Service.
This document is available in alternate formats or languages. For more information, call 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704.
Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM and Prescription Blue PDPSM are issued by Blue Cross Blue Shield of Michigan, which contracts with the federal government. Medicare Plus Blue PPOSM, Medicare Plus Blue PFFSSM and Prescription Blue PDP'sSM contracts with CMS are renewed annually and the availability of coverage beyond the end of the contract year is not guaranteed.
You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:
1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week;
The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778; or
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