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2017 PART D STEP THERAPY Criteria Premera Blue Cross Medicare Advantage HMO Plans premera.com/ma Last updated 11/2017 Customer Service Premera Blue Cross Medicare Advantage PO Box 4196, Portland, OR 97208-4196 Call toll free 888-850-8526 (TTY: 711). Representatives are available between 8 a.m. and 8 p.m., seven days a week. Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in Premera Blue Cross depends on contract renewal. The formulary may change at any time. You will receive notice when necessary. H7245_PBC0903_Accepted 029330 (11-2017)

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  • 2017 PART D STEP THERAPY C r i t e r i a Premera Blue Cross Medicare Advantage HMO Plans

    premera.com/ma

    Last updated 11/2017

    Customer Service Premera Blue Cross Medicare Advantage PO Box 4196, Portland, OR 97208-4196 Call toll free 888-850-8526 (TTY: 711). Representatives are available between 8 a.m. and 8 p.m., seven days a week.

    Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in Premera Blue Cross depends on contract renewal. The formulary may change at any time. You will receive notice when necessary.

    H7245_PBC0903_Accepted 029330 (11-2017)

  • HECTOROL/ZEMPLAR STEP THERAPY

    MEDICATION(S) SUBJECT TO STEP THERAPY DOXERCALCIFEROL 0.5 MCG CAP, DOXERCALCIFEROL 1 MCG CAPSULE, DOXERCALCIFEROL 2.5 MCG CAP, PARICALCITOL 1 MCG CAPSULE, PARICALCITOL 2 MCG CAPSULE, PARICALCITOL 4 MCG CAPSULE

    CRITERIA Patient must have tried calcitriol within 180 days of the date of service.

  • TRIPTAN STEP THERAPY

    MEDICATION(S) SUBJECT TO STEP THERAPY ZOLMITRIPTAN 2.5 MG TABLET, ZOLMITRIPTAN 5 MG TABLET, ZOLMITRIPTAN ODT

    CRITERIA Patient must have tried both sumatriptan and rizatriptan.

  • Multi-Language Insert

    Multi-Language Interpreter Services

    English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-850-8526 (TTY: 711).

    Spanish: ATENCIN: si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al 1-888-850-8526 (TTY: 711).

    Chinese: 1-888-850-8526TTY711

    Vietnamese: CH : Nu bn ni Ting Vit, c cc dch v h tr ngn ng min ph dnh cho bn. Gi s 1-888-850-8526 (TTY: 711).

    Korean: : , . 1-888-850-8526 (TTY: 711) .

    Russian: : , . 1-888-850-8526 (: 711).

    Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-850-8526 (TTY: 711).

    Ukrainian: ! , . 1-888-850-8526 (: 711).

    Mon-Khmer, Cambodian: , 1-888-850-8526 (TTY: 711)

    Japanese: 1-888-850-8526TTY:711

    Amharic: : 1-888-850-8526 ( : 711).

    Cushite (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-850-8526 (TTY: 711).

    Arabic: : . 711 ( : 8526-850-888-1).

    Punjabi: : , 1-888-850-8526 (TTY: 711) ' German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfgung. Rufnummer: 1-888-850-8526 (TTY: 711).

    Laotian: : , , , . 1-888-850-8526 (TTY: 711).

    Premera Blue Cross is an HMO plan with a with a Medicare contract. Enrollment in Premera Blue Cross depends on renewal. H7245_PBC0977_Accepted 028023 (11-2016)

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  • !!!!!!!!!!!!!!!!!!!!!!!!

    !

    Non-Discrimination Notice

    Discrimination is Against the Law Premera Blue Cross Medicare Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, ethnicity, national origin, color, religion, sex, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location.

    Premera: Provides free aids and services to people with

    disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large

    print, audio, accessible electronic formats, other formats)

    Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

    If you need these services, contact the Civil Rights Coordinator.

    If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Premera Blue Cross Medicare Advantage Plans, Attn: Civil Rights Coordinator, P.O. Box 4158, Portland, OR 97208-4158

    !

    Fax Number: 1-855-339-8129 Expedited appeal requests can be made by phone at 1-888-850-8526 (TTY: 711). Email: [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Ave SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Getting Help in Other Languages This Notice has important information. This notice may have important information about your application or coverage through Premera Blue Cross Medicare Advantage. There may be key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 888-850-8526 (TTY: 711).

    Premera Blue Cross is an HMO plan with a with a Medicare contract. Enrollment in Premera Blue Cross depends on renewal. H7245_PBC0979

    Part D Step Therapy CriteriaPART D STEP THERAPY Criteria Premera Blue Cross Medicare Advantage HMO Plans Customer Service Premera Blue Cross Medicare Advantage PO Box 4196, Portland, OR 97208-4196 Call toll free 888-850-8526 (TTY: 711). Representatives are available between 8 a.m. and 8 p.m., seven days a week. HECTOROL/ZEMPLAR STEP THERAPY MEDICATION(S) SUBJECT TO STEP THERAPY TRIPTAN STEP THERAPY MEDICATION(S) SUBJECT TO STEP THERAPY Multi-Language Insert Multi-Language Interpreter Services English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-850-8526 (TTY: 711). Non-Discrimination Notice


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