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

 

Section 5(f). Prescription Drug Benefits

 

Important things you should keep in mind about these benefits for members enrolled in our regular pharmacy program:
 
  • We cover prescription drugs and supplies, as described below and on the following pages for members enrolled in our regular pharmacy drug program.
     
  • If there is no generic drug available, you must pay the brand-name cost-sharing amount when you receive a brand-name drug.
     
  • If there is a generic substitution available and you or your provider requests a brand-name drug, you will be responsible for the applicable cost-share plus the difference in the costs of the brand-name and generic drugs.
     
  • If the cost of your prescription is less than your cost-sharing amount, you pay only the cost of your prescription.
     
  • 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.
     
  • Benefits for certain self-injectable (self-administered) drugs are provided only when they are dispensed by a pharmacy under the pharmacy benefit.
     
  • Benefits for certain auto-immune infusion medications (limited to Remicade, Renflexis and Inflectra) are covered only when they are obtained from a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center). See Drugs From Other Sources in this section for more information.
     
  • 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, or if you are age 65 or over.
     
  • Medication prices vary among different retail pharmacies and the Specialty Drug Pharmacy Program. Review purchasing options for your prescriptions to get the best price. A drug cost tool is available at www.fepblue.org or call:
     
    • Retail Pharmacy Program: 800-624-5060, TTY: 711
       
    • Specialty Drug Pharmacy Program: 888-346-3731, TTY: 711
       
  • YOU MUST GET PRIOR APPROVAL FOR CERTAIN DRUGS AND SUPPLIES, and prior approval must be renewed periodically. Prior approval is part of our Patient Safety and Quality Monitoring (PSQM) program. Please keep reading for more information about the PSQM program and refer to Section 3 for more information about prior approval. 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.
     
  • During the course of the year, we may move a brand-name drug from Tier 2 (preferred brand-name, preferred generic specialty and preferred brand-name specialty drugs) to noncovered if a generic equivalent or biosimilar becomes available or if new safety concerns arise. 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.
     
  • A pharmacy restriction may be applied for clinically inappropriate use of prescription drugs and supplies.
     
  • You must use Preferred FEP Blue Focus retail pharmacies or the Specialty Drug Pharmacy Program in order to receive benefits. Our specialty drug pharmacy is a Preferred pharmacy.
     
  • There is no calendar year deductible for the Retail Pharmacy Program or the Specialty Drug Pharmacy Program.
     
  • 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.