2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits
MPDP Overview

 

Section 5(f)(a). FEP Medicare Prescription Drug Program

Important things you should keep in mind about these benefits:
 
  • These prescription drug benefits are for members enrolled in our Medicare Part D Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP).
     
  • Members with Medicare Part A and/or Part B primary are eligible for the benefits under the FEP Medicare Prescription Drug Program.
     
  • For additional information about who is eligible for this program and when, or to dispute your claim, please visit us at www.fepblue.org/medicarerx
     
  • If you are a Postal Service annuitant and their covered Medicare-eligible family member, you will be automatically group enrolled in our PDP EGWP. Contact us for additional information at 888-338-7737.

Note: Notify us as soon as possible if you or your eligible family member is already enrolled in a Medicare Part D Plan. Enrollment in our FEP Prescription Drug Plan will cancel your enrollment in another Medicare Part D plan.

There are advantages to being enrolled in our FEP Medicare Prescription Drug Plan:
 
  • In our PDP EGWP, your cost-share for covered drugs, medications, and supplies will be equal to or better than the cost-share for those enrolled in our standard non-PDP EGWP Prescription Drug Program.
     
  • We may provide additional coverage for prescription drugs not included in your Medicare Part D For more information about your share of the cost or which prescription drugs may or may not be covered, please call 888-338-7737, TTY 711.
     
  • There is no calendar year deductible for drugs purchased under this program.
     
  • Certain medications may be covered under Medicare Part B or Medicare Part D, depending on the condition being treated.
     
  • If the cost of your prescription is less than your cost-sharing amount, you pay only the cost of your prescription.
     
  • In our FEP Medicare Prescription Drug Plan, you have a pharmacy network. You must go to a network pharmacy to obtain your prescriptions to be covered. If you are unable to get to a network pharmacy in certain situations such as during an emergency, you may pay for your prescriptions and request a reimbursement.
     
  • Medication prices vary among different pharmacies in our network. Review purchasing options for your prescriptions to get the best price. A drug cost tool is available at www.fepblue.org/medicarerx or call 888-338-7737, TTY: 711.

We cover prescription drugs, medications, and supplies as described below and on the following pages.
 
  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
     
  • The FEP Blue Focus formulary contains a comprehensive list of drugs under all therapeutic categories with two exceptions: some drugs, nutritional supplements and supplies are noncovered; we may also exclude certain U.S. FDA-approved drugs when multiple generic equivalents/alternative medications are available.
     
  • The Blue Cross and Blue Shield Service Benefit Plan’s FEP Blue Focus uses a closed formulary.
     
  • During the course of the year, we may move a brand-name drug from Tier 2 (preferred brand-name) to Tier 3 (non-preferred brand-name) if a generic equivalent becomes available or if new safety concerns If your drug is moved to a higher tier, your cost-share will increase. If your drug is moved to noncovered, you pay the full cost of the medication. Tier reassignments during the year are not considered benefit changes.
     
  • If there is no generic drug available, you must pay the brand-name cost-sharing amount when you receive a brand-name drug.
     
  • YOU OR YOUR PRESCRIBER MUST GET PRIOR APPROVAL FOR CERTAIN DRUGS AND SUPPLIES, and prior approval must be renewed periodically. 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.
     
  • Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage.
     
  • If you choose to opt out of or disenroll from our FEP Medicare Prescription Drug Plan, see Section 9 for additional FEP Medicare Prescription Drug Plan information and for our opt-out and disenrollment process. Contact us for assistance with the FEP Medicare Prescription Drug Plan opt out and disenrollment process at (888) 338-7737.
     
  • A restriction may be applied to prescriptions for drugs and supplies when there is misuse.
     
  • Members enrolled in the FEP Medicare Prescription Drug Program have no coverage for drugs obtained and/or purchased overseas.
     
  • Federal law prevents the pharmacy from accepting unused drugs, medications, and supplies.

Warning: If you opt out of or disenroll from our PDP EGWP, you will not have any PSHB Program prescription drug coverage.

Note: If you choose to opt out of or disenroll from our PDP EGWP, your premium will not be reduced, and you may have to wait to re-enroll during Open Season or for a QLE. If you do not maintain creditable coverage, re-enrollment in our PDP EGWP may be subject to a late enrollment penalty. Contact us for assistance with the PDP EGWP opt out disenrollment process.

We will send each new enrollee a Plan identification card, which covers pharmacy and medical benefits. Each new enrollee has access to our FEP Medicare Prescription Drug Program Evidence of Coverage, Summary of Benefits, Annual Notice of Change, and other resources at www.fepblue.org/medicarerx/resources.