2021 List of Covered Drugs (FORMULARY) - BCBSIL

1 Blue Cross Community MMAI (Medicare-Medicaid Plan)SM2021 List of Covered Drugs ( formulary )PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE Drugs WE COVER IN THIS PLANHPMS Approved formulary File ID: 00021147 Effective January 2021 For more recent information or other questions, contact us at 1-877-723-7702 (TTY 711). We are available seven (7) days a week. Our call center is open Monday-Friday 8:00 - 8:00 Central time. On weekends and Federal holidays, voice messaging is available. If you leave a voice message, a Member Services representative will return your call no later than the next business visit on 11/09/2021H0927_ILCOMP21 Blue Cross Community MMAI 2021 LIST OF Covered DRUGSIf you have questions, please call Blue Cross Community MMAI at 1-877-723-7702 (TTY 711). We are available seven (7) days a week. Our call center is open Monday-Friday 8:00 - 8:00 Central time.

2 On weekends and Federal holidays, voice messaging is available. If you leave a voice message, a Member Services representative will return your call no later than the next business day. The call is free. For more information, visit Cross Community MMAISM | 2021 list of covered drugs ( formulary )IntroductionThis document is called the List of Covered Drugs (also known as the drug List). It tells you which prescription Drugs and over-the-counter Drugs and items are Covered by Blue Cross Community MMAI. The drug List also tells you if there are any special rules or restrictions on any Drugs Covered by Blue Cross Community MMAI. Key terms and their definitions appear in the last chapter of the Member of ContentsA. Disclaimers ..iB. Frequently Asked Questions (FAQ) ..ivB1. What prescription Drugs are on the List of Covered Drugs ? (We call the List of Covered Drugs the drug List for short.)

3 IvB2. Does the drug List ever change? ..ivB3. What happens when there is a change to the drug List? ..vB4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain Drugs ? ..viB5. How will you know if the drug you want has limits or if there are required actions to take to get the drug ? ..viB6. What happens if we change our rules about some Drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? ..viB7. How can you find a drug on the drug List? ..viiB8. What if the drug you want to take is not on the drug List? ..viiB9. What if you are a new Blue Cross Community MMAI member and can t find your drug on the drug List or have a problem getting your drug ? ..viiB10. Can you ask for an exception to cover your drug ? ..viiiB11. How can you ask for an exception?.

4 IxB12. How long does it take to get an exception? ..ixB13. What are generic Drugs ? ..ixB14. What are OTC Drugs ? ..ixB15. Does Blue Cross Community MMAI cover non- drug OTC products? ..ixB16. What is your copay? ..ixB17. What are drug tiers? ..xBlue Cross Community MMAI 2021 LIST OF Covered DRUGSIf you have questions, please call Blue Cross Community MMAI at 1-877-723-7702 (TTY 711). We are available seven (7) days a week. Our call center is open Monday-Friday 8:00 - 8:00 Central time. On weekends and Federal holidays, voice messaging is available. If you leave a voice message, a Member Services representative will return your call no later than the next business day. The call is free. For more information, visit Overview of the List of Covered Drugs ..xiC1. Drugs Grouped by Medical Condition ..xivD. Index of Covered Drugs ..104 Blue Cross Community MMAI 2021 LIST OF Covered DRUGSiIf you have questions, please call Blue Cross Community MMAI at 1-877-723-7702 (TTY 711).

5 We are available seven (7) days a week. Our call center is open Monday-Friday 8:00 - 8:00 Central time. On weekends and Federal holidays, voice messaging is available. If you leave a voice message, a Member Services representative will return your call no later than the next business day. The call is free. For more information, visit DisclaimersThis is a list of Drugs that members can get in Blue Cross Community MMAI. Blue Cross Community MMAI is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects : If you speak English, language assistance services, free of charge, are available to you. Call 1-877-723-7702 (TTY 711). We are available seven (7) days a week.

6 Our call center is open Monday-Friday 8:00 - 8:00 Central time. On weekends and Federal holidays, voice messaging is available. If you leave a voice message, a Member Services representative will return your call no later than the next business day. The call is N: Si habla espa ol, los servicios de asistencia ling stica est n a su disposici n sin costo alguno para usted. Llame al 1-877-723-7702 (TTY 711). Estamos a su disposici n los siete (7) d as de la semana. Nuestra central telef nica est abierta de lunes a viernes de 8:00 a. m. a 8:00 p. m., hora del centro. Para los fines de semana y d as feriados federales, est disponible el servicio de mensajes de voz. Si deja un mensaje de voz, un representante de Atenci n al Asegurado le devolver la llamada antes del pr ximo d a can get this document for free in other formats, such as large print, braille, or audio.

7 Call 1-877-723-7702 (TTY 711). We are available seven (7) days a week. Our call center is open Monday-Friday 8:00 - 9:00 Central time. On weekends and Federal holidays, voice messaging is available. If you leave a voice message, a Member Services representative will return your call no later than the next business day. The call is can request to always have your materials sent to you in the language and/or format (such as large print, braille, or audio) that you need. Call 1-877-723-7702 (TTY 711). Once requested, Member Services will always send you materials in your chosen language and/or format until you request to have it changed. This service is free. Blue Cross Community MMAI 2021 LIST OF Covered DRUGSiiIf you have questions, please call Blue Cross Community MMAI at 1-877-723-7702 (TTY 711). We are available seven (7) days a week. Our call center is open Monday-Friday 8:00 - 8:00 Central time.

8 On weekends and Federal holidays, voice messaging is available. If you leave a voice message, a Member Services representative will return your call no later than the next business day. The call is free. For more information, visit Blue Cross and Blue Shield of Illinois complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Illinois does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Illinois: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters 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: Qualified interpreters Information written in other languages If you need these services, contact Civil Rights Coordinator.

9 If you believe that Blue Cross and Blue Shield of Illinois 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: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at , or by mail or phone at: Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at time.

10 On weekends and Federal holidays, voice messaging is available. If you leave a voice message, a Member Services representative will return your call no later than the next business day. The call is free. For more information, visit Blue Cross Community MMAI 2021 LIST OF Covered DRUGSiiiIf you have questions, please call Blue Cross Community MMAI at 1-877-723-7702 (TTY 711). We are available seven (7) days a week. Our call center is open Monday-Friday 8:00 - 8:00 Central ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-877-723-7702 (TTY/TDD: 711). ATENCI N: si habla espa ol, tiene a su disposici n servicios gratuitos de asistencia ling stica. Llame al 1-877-723-7702 (TTY/TDD: 711). UWAGA: Je eli m wisz po polsku, mo esz skorzysta z bezp atnej pomocy j zykowej. Zadzwo pod numer 1-877-723-7702 (TTY/TDD: 711).