2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits


Note: The calendar year deductible does not apply to covered prescription drugs unless specifically stated “(deductible applies).”
 
Important things you should keep in mind about these benefits:
  • We cover prescription drugs and supplies, as described in the chart beginning on page 95.
     
  • 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. See page 95 for specialty drug fills from a Preferred pharmacy.
     
  • Benefits for certain auto-immune infusion medications (limited to Remicade, Renflexis and Inflectra) are covered only when they are obtained by a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center). See Drugs From Other Sources in this Section, page 102, 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: 800-624-5077
    • Specialty Drug Pharmacy Program: 888-346-3731, TTY: 877-853-9549
       
  • 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 refer to page 94 for more information about the PSQM program and to Section 3 for more information about prior approval.
     
  • 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 non-covered if a generic equivalent or biosimilar becomes available or if new safety concerns arise. If your drug is moved to non-covered, 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 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 non-covered (see page 101); we may also exclude certain U.S. FDA-approved drugs when multiple generic equivalents/alternative medications are available. See page 93 for details.
     
  • The Blue Cross and Blue Shield Service Benefit Plan’s FEP Blue Focus uses a closed formulary, see page 92.
 
We will send each new enrollee an FEP Blue Focus identification card, which covers all pharmacy and medical benefits.

There are important features you should be aware of. These include:
  • Who can write your prescriptions. A physician or dentist licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, or, in states that permit it, a licensed/certified provider with prescriptive authority prescribing within their scope of practice must write your prescriptions. See Section 5(i) for drugs purchased overseas.
     
  • Where you can obtain them.
    You must fill prescriptions only at a Preferred retail pharmacy or through the Specialty Drug Pharmacy Program, in order to receive benefits. See page 138 for the definition of “specialty drugs.” For information about prescriptions obtained from an overseas retail pharmacy, see page 110.


    The Retail Pharmacy Program is administered by CVS Caremark. For a listing of Preferred retail pharmacies, call the Retail Pharmacy Program at 800-624-5060, TTY: 800-624-5077, or visit our website, www.fepblue.org.

    Note: If your prescription requires prior approval and you have not yet obtained prior approval, you must pay the full cost of the drug or supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed. Please refer to Section 7 for instructions on how to file prescription drug claims.

    The Specialty Drug Pharmacy Program is administered by AllianceRx Walgreens Prime.

    Notes:
  • The Specialty Drug Pharmacy Program will not fill your prescription until you have obtained prior approval. AllianceRx Walgreens Prime, the program administrator, will hold your prescription for up to 30 days. If prior approval is not obtained within 30 days, your prescription will be returned to you along with a letter explaining the prior approval procedures.
     
  • Preferred retail pharmacies may offer options for ordering prescription drugs online. Drugs ordered online may be delivered to your home and these online orders are a part of the Retail Prescription Drug Program described on page 95.
     
  • Due to manufacturer restrictions, a small number of specialty drugs used to treat rare or uncommon conditions may be available only through a Preferred retail pharmacy. See page 100 for information about your cost-share for specialty drugs purchased at a Preferred retail pharmacy that are affected by these restrictions.
 
  • What is covered.
    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.

Some drugs, nutritional supplements, and supplies are not covered (see page 101); 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:
  • 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 our Pharmacy and Medical Policy 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: Preferred generic drugs obtained at a Preferred retail pharmacy
Tier 2: Preferred brand-name drugs, preferred generic specialty drugs, and preferred brand-name specialty drugs obtained at a Preferred retail pharmacy or through the Specialty Drug Pharmacy Program.

You can view the formulary on our website at www.fepblue.org or call 800-624-5060, TTY: 800-624-5077, for assistance. If you do not find your drug on the formulary, or the preferred drug list, please call 800-624-5060. Changes to the formulary are not considered benefit changes.

Any savings we receive on the cost of drugs purchased under this Plan from drug manufacturers are credited to the reserves held for this Plan.
 
  • Generic equivalents
    Generic equivalent drugs have the same active ingredients as their brand-name equivalents. By filling your prescriptions (or those of family members covered by the Plan) at a Preferred retail pharmacy or through the Specialty Drug Pharmacy Program, you authorize the pharmacist to substitute any available Federally approved generic equivalent, unless you or your physician specifically request a brand-name drug. However, 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. Keep in mind that FEP Blue Focus members must use Preferred pharmacies in order to receive benefits. See page 133 for more information about generic alternatives and generic equivalents.
 
  • Disclosure of information. As part of our administration of prescription drug benefits, we may disclose information about your prescription drug utilization, including the names of your prescribing physicians, to any treating physicians or dispensing pharmacies.
 
  • These are the dispensing limitations.
    Subject to manufacturer packaging and your prescriber’s instructions, you may purchase either up to a 30-day supply or a 31 to 90 day supply of covered drugs and supplies through the Retail Pharmacy Program or up to a 30-day supply through the Specialty Drug Pharmacy Program. 
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. See the contact information on page 94.
     
  • Benefits for certain self-injectable (self-administered) drugs are provided only when they are dispensed by a pharmacy under the pharmacy benefit. Medical benefits will be provided for a once-per-lifetime dose per therapeutic category of drugs dispensed by your provider or any non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B coverage. See page 95 for specialty drug fills from a Preferred pharmacy.
     
  • Benefits for certain auto-immune infusion medications (Remicade, Renflexis and Inflectra) are provided only when they are obtained by a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center). See Drugs From Other Sources in this section, page 102, for more information.
 
  • Important contact information
     
    • Retail Pharmacy Program: 800-624-5060, TTY: 800-624-5077
       
    • Specialty Drug Pharmacy Program: 888-346-3731, TTY: 877-853-9549; or www.fepblue.org.
 
Patient Safety and Quality Monitoring (PSQM)

We have a special program to promote patient safety and monitor healthcare quality. Our Patient Safety and Quality Monitoring (PSQM) program features a set of closely aligned programs that are designed to promote the safe and appropriate use of medications. Examples of these programs include:

 
  • Prior approval – As described below, this program requires that approval be obtained for certain prescription drugs and supplies before we provide benefits for them.
     
  • Safety checks – Before your prescription is filled, we perform quality and safety checks for usage precautions, drug interactions, drug duplication, excessive use, and frequency of refills.
     
  • Quantity allowances – Specific allowances for several medications are based on U.S. FDA-approved recommendations, national scientific and generally accepted standards of medical practice guidelines (such as Centers for Disease Control, American Medical Association, etc.), and manufacturer guidelines.

For more information about our PSQM program, including listings of drugs subject to prior approval or quantity allowances, visit our website at www.fepblue.org or call the Retail Pharmacy Program at 800-624-5060, TTY: 800-624-5077.
 
Prior Approval

As part of our Patient Safety and Quality Monitoring (PSQM) program (see above), you must make sure 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. Prior approval must be renewed periodically. To obtain a list of these drugs and supplies and to obtain prior approval request forms, call the Retail Pharmacy Program at 800-624-5060, TTY: 800-624-5077. You can also obtain the list and forms through our website at www.fepblue.org. Please read Section 3 for more information about prior approval.

Notes:
  • Updates to the list of drugs and supplies requiring prior approval are made periodically during the year. New drugs and supplies may be added to the list and prior approval criteria may change. Changes to the prior approval list or to prior approval criteria are not considered benefit changes.
     
  • If your prescription requires prior approval and you have not yet obtained prior approval, you must pay the full cost of the drug or supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed. Please refer to Section 7 for instructions on how to file prescription drug claims.
     
  • It is your responsibility to know the prior approval authorization expiration date for your medication. We encourage you to work with your physician to obtain prior approval renewal in advance of the expiration date.