2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f)(a). FEP Medicare Prescription Drug Program
Page 92
Section 5(f)(a). FEP Medicare Prescription Drug Program
Page 92
Some drugs, nutritional supplements, and supplies are not covered; we may also exclude certain U.S. FDA-approved drugs when multiple generic equivalents/alternative medications are available. If you purchase a drug, nutritional supplement, or supply that is not covered, you will be responsible for the full cost of the item.
Notes:
Your cooperation with our cost-saving efforts helps keep your premium affordable. Our payment levels are generally categorized as:
Tier 1: Includes generic drugs
Tier 2: Includes preferred brand-name drugs
Tier 3: Includes non-preferred brand-name drugs
Tier 4: Includes preferred specialty drugs
Changes to the formulary are not considered benefit changes.
Any savings we receive on the costs of drugs purchased under this Plan from drug manufacturers are credited to the reserves held for this Plan.
Notes:
- Before filling your prescription, please check the FEP Blue Focus Formulary drug list and tier assignment of the drug. Other than changes resulting from new drugs or safety issues, the preferred drug list is updated periodically during the year and not considered a benefit change.
- Member cost-share for prescription drugs is determined by the tier to which a drug has been assigned. To determine the tier assignments for formulary drugs, we work with the CVS Caremark National Pharmacy and Therapeutics Committee, a group of physicians and pharmacists who are not employees or agents of, nor have financial interest in, the Blue Cross and Blue Shield Service Benefit Plan. The Committee meets quarterly to review new and existing drugs to assist us in our assessment. Drugs determined to be of equal therapeutic value and similar safety and efficacy are then evaluated on the basis of cost. The Committee’s recommendations, together with our evaluation of the relative cost of the drugs, determine the placement of formulary drugs on a specific tier. Using lower cost preferred generic drugs will provide you with a high-quality, cost-effective prescription drug benefit.
Your cooperation with our cost-saving efforts helps keep your premium affordable. Our payment levels are generally categorized as:
Tier 1: Includes generic drugs
Tier 2: Includes preferred brand-name drugs
Tier 3: Includes non-preferred brand-name drugs
Tier 4: Includes preferred specialty drugs
Changes to the formulary are not considered benefit changes.
Any savings we receive on the costs of drugs purchased under this Plan from drug manufacturers are credited to the reserves held for this Plan.
- These are the dispensing limitations.
Notes:
- Certain drugs such as narcotics may have additional limits or requirements as established by the U.S. FDA or by national scientific or medical practice guidelines (such as Centers for Disease Control, American Medical Association, etc.) on the quantities that a pharmacy may dispense. In addition, pharmacy dispensing practices are regulated by the state where they are located and may also be determined by individual pharmacies. Due to safety requirements, some medications are dispensed as originally packaged by the manufacturer and we cannot make adjustments to the packaged quantity or otherwise open or split packages to create 30, and 90-day supplies of those medications. In most cases, refills cannot be obtained until 75% of the prescription has been used. Controlled substances cannot be refilled until 80% of the prescription has been used. Controlled substances are medications that can cause physical and mental dependence, and have restrictions on how they can be filled and refilled. They are regulated and classified by the DEA (Drug Enforcement Administration) based on how likely they are to cause dependence. Call us or visit our website if you have any questions about dispensing limits. Please note that in the event of a national or other emergency, or if you are a reservist or National Guard member who is called to active military duty, you should contact us regarding your prescription drug needs.
- We may require Prior Approval for Drug on the Formulary (or when you need a drug that is not listed on the Formulary)
You must make sure that your physician obtains prior approval for certain prescription drugs and supplies in order to use your prescription drug coverage. In providing prior approval, we may limit benefits to quantities prescribed in accordance with generally accepted standards of medical, dental, or psychiatric practice in the United States. Our prior approval process may include step therapy, which requires you to use a generic and/or preferred medication(s) before a non-preferred medication is covered. Prior approval must be renewed periodically. To obtain a list of these drugs and supplies and to obtain prior approval request forms, call the FEP Medicare Prescription Drug Program at 888-338-7737, TTY: 711. You can also obtain the list of forms through our website at www.fepblue.org. Please read Section 3 for more information about prior approval.