Senior Care Options

Review clinical criteria and submit a prior authorization if necessary.

BMC HealthNet Plan members and providers can search the BMC HealthNet Plan Senior Care Options Formulary for coverage of specific medications. If the provider feels that it is medically necessary for a member to take a medication excluded by our pharmacy program, he/she may submit a prior authorization request to the Plan by fax or online submission using the appropriate form below.

  • If the request meets criteria, BMC HealthNet Plan will cover the drug.
  • If the request is denied, the member and the authorized appeal representative have the right to appeal the decision. 

Please review clinical criteria before submitting prior authorization requests. Contact us with questions about guidelines, submitting forms, or to request a printed version of any guideline or form.

If you have a J-Code, please search our drug formulary by drug name. Not all services and procedures that require prior authorization may be listed. If you don't see a service or procedure in our matrix, please contact us.

Vaccines are covered under both Medicare Part B and Medicare Part D depending on the circumstances. In order to facilitate appropriate coverage and reporting of vaccines for Medicare enrollees in compliance with Medicare rules and regulations our Senior Care Options vaccine coverage is administered as follows:

Part B Vaccines:

  • Pneumococcal
  • Influenza
  • Hepatitis B for Moderate or High Risk Individuals
  • Vaccines used for treatment

*Part B vaccines can be administered by a physician in office and billed to BMC HealthNet Plan or received at a network pharmacy

Part D Vaccines:

  • Any vaccine not listed above, which is prescribed for preventive purposes (i.e. Zostavax)
  • A list of covered Part D vaccines is provided in the Plan formulary

Part D Vaccines have several options for coverage:

  • Pharmacy administration (Preferred Method) – Member obtains vaccine at a network pharmacy where it is administered by a pharmacist.
  • Provider administration of vaccine purchased at pharmacy (Alternative Method 1) – Physician supplies the member with a prescription for the vaccine. Member picks up the prescription from the pharmacy and brings back to the provider office for administration.
  • Provider administration with the vaccine supplied by the provider (Alternative Method 2) – Provider will need to use the reimbursement form to bill for Part D vaccines that are supplied and administered in office.
    *It is anticipated that this method will be utilized by participating provider when there is considerable hardship due to member transportation or mobility restrictions that would preclude the member from getting the vaccine at a network pharmacy.

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