The RxBLUE (PDP) Formulary is a list of all drugs covered under your plan. The formulary consists of more than 1,400 medications. Additionally, we provide monthly formulary updates to keep information current.

View the RxBLUE (PDP) Formulary
The formulary is current as of October 2009. For changes since that date, view the latest formulary update below.

2010 Formulary Update 
This document shows any medication changes made to the plan since October 2009.

Prior Authorization Criteria
This is a list of drugs that require prior approval before they can be filled.

Quantity Limit Requirements
These drugs have restrictions on fill amounts.

Step Therapy Criteria
These drugs require the use of an alternative (typically generic) medication first.

Why choose generics?
RxBLUE (PDP) covers both brand-name drugs and generic drugs. Generic drugs have the same active ingredient as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.

You will notice that the formulary offers generic substitutions for brand-name drugs when possible. By choosing generics, you will still get effective, safe treatment, and you may save money.

Can the RxBLUE (PDP) formulary change?
Yes, drugs may be added or removed from our formulary during the year. The formulary is current as of October 2009 and is valid through Dec. 31, 2010.

Can I receive coverage for drugs not on the formulary?
Yes, if you believe you are entitled to payment or benefits on a certain drug, you can request a coverage determination. A coverage determination is a decision made by RxBLUE (PDP) regarding payment for a Part D drug or exceptions to our formulary. If your coverage determination is denied, you can appeal the decision by asking for a redetermination of the original request. Full details on coverage determinations and appeals can be found in the Evidence of Coverage (Chapter 7, pages 72–95). Read more information regarding exceptions, appeals and complaints by viewing the Your Rights page of this website.

Learn more about submitting Coverage Determinations, Appeals or Complaints

What if I’m already taking a drug RxBLUE (PDP) doesn’t cover?
During the first 90 days of enrollment, we extend up to a one-month transition supply of medication (unless the prescription is written for fewer days) to members for drugs that are not on our formulary as well as drugs with restrictions or limits. Call Customer Service to find out more.

Filing claims
RxBLUE (PDP) offers automatic claims filing on your behalf. Should you need to file a claim yourself, please use the prescription drug claim form.

Our Organization contracts with the Federal government. RxBLUE (PDP) is a stand-alone prescription drug plan with a Medicare contract.

Note: Files in Adobe PDF format require Adobe Acrobat Reader to open. You can download Adobe Acrobat Reader for free by clicking the graphic below.

Pending CMS Approval