2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f)(a). FEP Medicare Prescription Drug Program
Page 91
Section 5(f)(a). FEP Medicare Prescription Drug Program
Page 91
- 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.
There are important features you should be aware of. These include:
- Who can write your prescription. A licensed physician or dentist in the United States, Puerto Rico, or the U.S. Virgin Islands, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication. Your prescribers must have Medicare-approved prescriptive authority.
- Where you can obtain prescription drugs.
You may fill prescriptions at a pharmacy that participates in our nationwide network. The network includes retail pharmacies and Specialty pharmacies. You may also receive your medication from a long-term care pharmacy when your care is handled in or by a long-term care facility. You will receive information on how to obtain a copy of the pharmacy directory, which lists all pharmacies participating in our network, in your enrollment package. You may also go online to our webpage, www.fepblue.org/medicarerx/resources for a complete listing.
Network retail pharmacies may offer options for ordering prescription drugs online. Drugs ordered online may be delivered to your home and these online orders are part of the Retail Prescription Drug Program described in this section.
- We have a managed formulary. Your provider may prescribe drugs that are subject to additional review to determine they are medically necessary. You may view our FEP Blue Focus formulary on our website at www.fepblue.org, or call us at 800-624-5060, TTY: 711, for assistance.
We use a closed formulary.
If you purchase a drug that is not on the formulary, you will pay the full cost of that drug.
The FEP Blue Focus Formulary includes a list of preferred drugs that are safe, effective and appropriate for our members and are available at lower costs than other drugs.