Name of Manual - Blue Cross and Blue Shield of Minnesota

Health Care Options
MedicareBlue PPO
(Regional PPO)
(continued)
PLEASE NOTE: The Blue Cross provider manual is not
applicable to this product, nor is the Blue Cross provider
services number. Provider information for MedicareBlue PPO
can be found at:
http://www.yourmedicaresolutions.com/for_providers/
This product is also available for fully insured employer groups to
purchase for their Medicare eligible members. Benefits may vary
by group.
MedicareBlue Rx (PDP) Another recent introduction in the Blue Cross Medicare product
portfolio is MedicareBlue Rx. This is a regional Medicare Part D
Program product offered through the coordination of six Blue
Cross plans covering seven states. The service area for this plan
encompasses Iowa, Minnesota, Montana, Nebraska, North Dakota,
South Dakota and Wyoming. The plan was introduced across the
region with a first effective date of January 1, 2006.
This product, as of January 1, 2011, offers two different benefit
level options: Standard and Premier. The design of Standard
includes a $310 annual deductible, 25 percent coinsurance and a 4
tier formulary. Premier has no annual deductible and has copays or
coinsurance depending on the drug’s formulary placement, which
is 4 tiers, and has some benefits in the coverage gap. Both plan
options include catastrophic coverage after $4,550 annual out of
pocket and formulary exceptions processes. Drugs in the
formularies may be subject to step therapy, quantity limits, or prior
authorization.
PLEASE NOTE: Forms, formularies and provider
information for MedicareBlue Rx can be found at:
http://www.yourmedicaresolutions.com/for_providers/
This product is also available for fully insured employer groups to
purchase for their Medicare eligible members. The logo on the
member ID card for any such group members will be prefaced
with “Group”. Benefits may vary by group.
5-14 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10)