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).”
 
Benefits Description

Covered Medications and Supplies
Preferred retail pharmacies

Preferred Generic Drugs obtained at Preferred retail and overseas retail pharmacies:

Tier 1


Notes:

 
  • See Section 5(i), page 110, for information on how to file claims for overseas services.
     
  • For prescription drugs billed for by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on this page for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy.

You Pay
Preferred retail and overseas retail pharmacy:

 
  • $5 copayment for each purchase of up to a 30-day supply
     
  • $15 copayment for each purchase of a 31 to 90-day supply

Non-preferred pharmacy: You pay all charges
 
Benefit Description
Preferred Brand-Name Drugs obtained at Preferred retail and overseas retail pharmacies:

Tier 2


Notes:

 
  • See Section 5(i), page 110, for information on how to file claims for overseas services.
     
  • For prescription drugs billed for by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on this page for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy.

You Pay
Preferred retail and overseas retail pharmacy:

 
  • 40% of the Plan allowance (up to a $350 maximum) for each purchase of up to a 30-day supply
     
  • 40% of the Plan allowance (up to a $1,050 maximum) for each purchase of up to a 90-day supply

Non-preferred pharmacy: You pay all charges
 
Benefit Description
Preferred specialty drugs (generic and brand-name) obtained at Preferred retail and overseas retail pharmacies:

Tier 2
  • Benefits for specialty drugs purchased at a Preferred retail pharmacy are limited to one purchase of up to a 30-day supply for each prescription dispensed.

Notes:

 
  • All refills must be obtained through the Specialty Drug Pharmacy Program. See page 100 for more information.
     
  • See the Specialty Drug Pharmacy Program for applicable cost shares and limits on page 100.
     
  • Due to safety requirement, some medications are dispensed as originally packaged by the manufacturer and we cannot make adjustment to the packaged quantity or otherwise open or split packages to create a 30-day supply of these medications.
     
  • For prescription drugs billed for by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on this page for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy.
     
  • See Section 5(i), page 110, for information on how to file claims for overseas services.

You Pay
Preferred retail and overseas retail pharmacy:

 
  • 40% of the Plan allowance (up to a $350 maximum) for each purchase of up to a 30-day supply
     
  • If a 31 to 90-day supply of a specialty drug has to be dispensed due to manufacturer packaging, you pay 40% of the Plan allowance (up to a $1,050 maximum) for each purchase.

Non-preferred pharmacy: You pay all charges
 
Benefits Description
Tier 1 and 2 drugs purchased from a Preferred pharmacy include, but are not limited to the following:

 
  • Drugs, vitamins and minerals, and nutritional supplements included in our closed formulary that by Federal law of the United States require a prescription for their purchase

    Note: See page 98 for our coverage of medications to promote better health as recommended under the Affordable Care Act.

     
  • Specialized nutritional formulas for children up to age 22 to treat inborn errors of amino acid metabolism
     
    • Must meet the definition of medical food (see definition on page 134)
       
    • Must be intended for use solely under medical supervision in the dietary management of an inborn error of amino acid metabolism
       
    • Must be receiving active, regular and ongoing medical supervision and must be unable to manage your condition by modification of diet alone
       
  • Medical foods, as defined by the U.S. FDA, that are administered orally and that provide the sole source (100%) of nutrition, for children up to age 22, for up to one year following the date of the initial prescription or physician order for the medical food (e.g., Neocate) in formula form only.

    Notes:

     
    • A prescription and prior approval are required for medical foods provided under the pharmacy benefit.
       
    • See Section 5(a), page 56, for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube.
       
  • Insulin, diabetic test strips, and lancets
    Note: See page 56 for our coverage of insulin pumps.

     
  • Needles and disposable syringes for the administration of covered medications
     
  • Clotting factors and anti-inhibitor complexes for the treatment of hemophilia
     
  • Drugs to aid smoking, tobacco, and E-cigarette cessation that require a prescription by Federal law

    Notes:

     
    • We provide benefits for over-the-counter (OTC) smoking, tobacco, and E-cigarette cessation medications only as described on page 100.
       
    • You may be eligible to receive smoking, tobacco, and E-cigarette cessation medications at no charge. See page 100 for more information.
       
  • Drugs for the diagnosis of infertility, except as described on page 101
     
  • Drugs to treat gender dysphoria (gonadotropin-releasing hormone (GnRH) antagonists and testosterones
     
  • Contraceptive drugs and devices, limited to:
     
    • Diaphragms and contraceptive rings
       
    • Injectable contraceptives
       
    • Intrauterine devices (IUDs)
       
    • Implantable contraceptives
       
    • Oral and transdermal contraceptives

Note: We waive your cost-share for generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative, when you purchase them at a Preferred retail pharmacy.


You Pay
See pages 95 and 99
 
Benefit Description
Over-the-counter (OTC) contraceptive drugs and devices, for women only, limited to:

 
  • Emergency contraceptive pills
     
  • Female condoms
     
  • Spermicides
     
  • Sponges

Note: We provide benefits in full for OTC contraceptive drugs and devices for women only when the contraceptives meet U.S FDA standards for OTC products. To receive benefits, you must use a Preferred retail pharmacy and present the pharmacist with a written prescription from your physician.


You Pay
Preferred retail and overseas retail pharmacy: Nothing

Non-preferred retail pharmacy: You pay all charges

Note: See Section 5(i), page 110, for information on how to file claims for overseas services.
 
Benefit Description
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network (see below) and administered in compliance with applicable state law and pharmacy certification requirements. See pages 45 and 46 for specific coverage.


Note: Our vaccine network is a network of Preferred retail pharmacies that have agreements with us to administer one or more routine immunizations. Check with your pharmacy or call our Retail Pharmacy Program at 800-624-5060, TTY: 800-624-5077, to find out which vaccines your pharmacy can provide.

You Pay
Preferred retail and overseas retail pharmacy: Nothing

Non-preferred retail pharmacy: You pay all charges

Notes:
  • You pay nothing for Influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
     
  • See Section 5(i), page 110, for information on how to file claims for overseas services.
 
Benefit Description
Diabetic Meter Program

Members with diabetes may obtain one glucose meter kit every 365 days at no cost through our Diabetic Meter Program. To use this program, you must call the telephone number listed below and request one of the eligible types of meters. The types of glucose meter kits available through our program are subject to change.

To order your free glucose meter kit, call us toll-free at 855-582-2024, Monday through Friday, from 9 a.m. to 7 p.m., Eastern Time, or visit our website at www.fepblue.org. The selected meter kit will be sent to you within 7 to 10 days of your request.

Note: Contact your physician to obtain a new prescription for the test strips and lancets to use with the new meter. Benefits will be provided for the test strips at Tier 2 (preferred brand-name) benefit payment levels if you purchase brand-name strips at a Preferred retail pharmacy. See page 99 for more information.

You Pay
Nothing for a glucose meter kit ordered through our Diabetic Meter Program

When obtained from any other source: You pay all charges
 
Benefits Description
Medications to promote better health as recommended under the Patient Protection and Affordable Care Act (the “Affordable Care Act”), limited to:

 
  • Iron supplements for children from age 6 months through 12 months
     
  • Oral fluoride supplements for children from age 6 months through 5 years
     
  • Folic acid supplements, 0.4 mg to 0.8 mg, for women capable of pregnancy
     
  • Low-dose aspirin (81 mg per day) for pregnant members at risk for preeclampsia
     
  • Aspirin for men age 45 through 79 and women age 50 through 79
     
  • Generic cholesterol-lowering statin drugs

Notes:

 
  • Benefits are not available for acetaminophen, ibuprofen, naproxen, etc.
     
  • Benefits for the medications listed above are subject to the dispensing limitations described on page 93 and are limited to recommended prescribed limits.
     
  • To receive benefits, you must use a Preferred retail pharmacy and present a written prescription from your physician to the pharmacist.
     
  • A complete list of USPSTF-recommended preventive care services is available online at: www.healthcare.gov/preventive-care-benefits. See pages 41-47 and 78 in Section 5(a) and 5(c) for information about other covered preventive care services.
     
  • See page 100 for our coverage of smoking, tobacco, and E-cigarette cessation medications.

You Pay
Preferred retail and overseas retail pharmacy: Nothing

Non-preferred retail pharmacy: You pay all charges

Note: See Section 5(i), page 110, for information on how to file claims for overseas services.
 
Benefits Description
Generic medications (limited to tamoxifen and raloxifene) to reduce breast cancer risk for women, age 35 or over, who have not been diagnosed with any form of breast cancer

Note: Your physician must send a completed Coverage Request Form to CVS Caremark before you fill the prescription. Call CVS Caremark at 800-624-5060, TTY: 800-624-5077, to request this form. You can also obtain the Coverage Request Form through our website at www.fepblue.org.

You Pay
Preferred retail and overseas retail pharmacy: Nothing

Non-preferred retail pharmacy: You pay all charges
 
Benefits Description
Opioid Reversal Agents: Tier 1 medications limited to Narcan nasal spray and naloxone generic injectable

You Pay
Preferred retail and overseas retail pharmacy: Nothing for the purchase of one 90-day supply per calendar year

Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost share.

Non-preferred retail pharmacy: You pay all charges
 
Benefit Description
Here is how to obtain your prescription drugs and supplies:

Preferred Retail Pharmacies

 
  • Make sure you have your ID card when you are ready to purchase your prescription.
     
  • Go to any Preferred retail pharmacy, or
     
  • Visit the website of your Preferred retail pharmacy to request your prescriptions online and delivery, if available.
     
  • 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.

Notes:

 
  • Benefits for Tier 2 specialty drugs purchased at a Preferred retail pharmacy are limited to one purchase of up to a 30-day supply for each prescription dispensed. All refills must be obtained through the Specialty Drug Pharmacy Program, see page 100 for more information.
     
  • Retail pharmacies that are Preferred for prescription drugs are not necessarily Preferred for durable medical equipment (DME) and medical supplies. To receive Preferred benefits for DME and covered medical supplies, you must use a Preferred DME or medical supply provider. See Section 5(a) for the benefit levels that apply to DME and medical supplies.
     
  • For prescription drugs billed for by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on this page for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy.
     
  • For a list of the Preferred Network Long Term Care pharmacies, call 800-624-5060, TTY: 800-624-5077.
     
  • For coordination of benefits purposes, if you need a statement of Preferred retail pharmacy benefits in order to file claims with your other coverage when this Plan is the primary payor, call the Retail Pharmacy Program at 800-624-5060, TTY: 800-624-5077, or visit our website at www.fepblue.org.

You Pay
Preferred retail and overseas retail pharmacy:

Tier 1
  • $5 copayment for each purchase of up to a 30-day supply
     
  • $15 copayment for each purchase of a 31 to 90-day supply

Tier 2
  • 40% of the Plan allowance (up to a $350 maximum) for each purchase of up to a 30-day supply
     
  • 40% of the Plan allowance (up to a $1,050 maximum) for each purchase of a 31 to 90-day supply

Non-preferred pharmacy: You pay all charges
 
Benefits Description
Smoking, Tobacco, and E-Cigarette Cessation Medications


If you are a covered member, you may be eligible to obtain specific prescription generic and brand-name smoking, tobacco, and E-cigarette cessation medications at no charge. Additionally, you may be eligible to obtain over-the-counter (OTC) smoking, tobacco, and E-cigarette cessation medications, prescribed by your physician, at no charge. These benefits are only available when you use a Preferred retail pharmacy.

Note: There may be age-restrictions based on U.S. FDA guidelines for these medications.

The following medications are covered through this program:

 
  • Generic medications available by prescription:
     
    • Bupropion ER 150 mg tablet
       
    • Bupropion SR 150 mg tablet
       
  • Brand-name medications available by prescription:
     
    • Chantix 0.5 mg tablet
       
    • Chantix 1 mg continuing monthly pack
       
    • Chantix 1 mg tablet
       
    • Chantix starting monthly pack
       
    • Nicotrol cartridge inhaler
       
    • Nicotrol NS Spray 10 mg/ml
       
  • Over-the-counter (OTC) medications

Notes:

 
  • To receive benefits for over-the-counter (OTC) smoking, tobacco, and E-cigarette cessation medications, you must have a physician’s prescription for each OTC medication that must be filled by a pharmacist at a Preferred retail pharmacy.
     
  • Regular prescription drug benefits will apply to purchases of smoking, tobacco, and E-cigarette cessation medications not meeting these criteria. Benefits are not available for over-the-counter (OTC) smoking, tobacco, and E-cigarette cessation medications except as described above.
     
  • See page 58 for our coverage of smoking, tobacco, and E-cigarette cessation treatment, counseling, and classes.

You Pay
Preferred retail pharmacy: Nothing

Non-preferred retail pharmacy: You pay all charges
 
Benefits Description
Specialty Drug Pharmacy Program


We cover specialty drugs that are listed on the FEP Blue Focus Specialty Drug List. This list is subject to change. For the most up-to-date list, call the telephone number below or visit our website, www.fepblue.org. (See page 138 for the definition of “specialty drugs.”)

Each time you order a new specialty drug or refill, a Specialty Drug pharmacy representative will work with you to arrange a delivery time and location that are most convenient for you, as well as ask you about any side effects you may be experiencing. See page 116 for more details about the Program.

Note: 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 a 30-day supply of these medications.


Contact Us: If you have any questions about this program, or need assistance with your specialty drug orders, please call 888-346-3731, TTY: 877-853-9549.


You Pay
Specialty Drug Pharmacy Program

Tier 2:
  • 40% of the Plan allowance (up to a $350 maximum) for each purchase of up to a 30-day supply
     
  • If a 31 to 90-day supply of a specialty drug has to be dispensed due to manufacturer packaging, you pay 40% of the Plan allowance (up to a $1,050 maximum) for each purchase.

Non-preferred specialty drug pharmacy: You pay all charges
 
Benefit Description
Not covered:

 
  • Drugs and supplies purchased from a Non-preferred pharmacy
     
  • Medical foods administered orally are not covered if not obtained at a Preferred retail pharmacy
     
  • Medical supplies such as dressings and antiseptics
     
  • Drugs and supplies for cosmetic purposes
     
  • Drugs and supplies for weight loss
     
  • Drugs for orthodontic care, dental implants, and periodontal disease
     
  • Drugs used in conjunction with assisted reproductive technology (ART) and assisted insemination procedures
     
  • Insulin and diabetic supplies except when obtained from a Preferred retail pharmacy or except when Medicare Part B is primary. See pages 56 and 96.
     
  • Medications and orally taken nutritional supplements that do not require a prescription under Federal law even if your doctor prescribes them or if a prescription is required under your state law
     
  • Products and foods other than liquid formulas or powders mixed to become formulas; foods and formulas readily available in a retail environment and marketed for persons without medical conditions; low-protein modified foods (e.g., pastas, breads, rice, sauces and baking mixes); nutritional supplements, energy products; and similar items

    Notes:

     
    • See Section 5(a), page 56, for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube.
       
    • See page 98 for our coverage of medications recommended under the Affordable Care Act and page 100 for smoking and tobacco cessation medications.
       
  • Infant formula other than described on pages 56 and 96
     
  • Drugs not listed on the formulary or preferred drug list
     
  • Brand name opioids
     
  • Remicade, Renflexis, and Inflectra are not covered for prescriptions obtained from a Preferred retail pharmacy, or through the Specialty Drug Pharmacy Program
     
  • Drugs for which prior approval has been denied or not obtained
     
  • Drugs and supplies related to sexual dysfunction or sexual inadequacy
     
  • Drugs and covered-drug-related supplies for the treatment of gender dysphoria if not obtained from a Preferred retail pharmacy or the Specialty Drug Pharmacy Program as described on pages 95 and 100
     
  • Drugs purchased through the mail or internet from pharmacies inside or outside the United States by members located in the United States
     
  • Over-the-counter (OTC) contraceptive drugs and devices, except as described on pages 96-97
     
  • Drugs used to terminate pregnancy
     
  • Sublingual allergy desensitization drugs, except as described on page 51

You Pay
All charges
 
Benefit Description

Drugs From Other Sources

Covered prescription drugs and supplies not obtained at a retail pharmacy or through the Specialty Drug Pharmacy Program to include, but not limited to:

 
  • Physician’s office – for more information refer to Section 5(a)
     
  • Facility (inpatient or outpatient) – for more information refer to Section 5(c)
     
  • Hospice agency – for more information refer to Section 5(c)
     
  • Drugs obtained at a physician’s office, inpatient or outpatient facility or hospice agency while overseas, see Section 5(i)
     
  • Drugs and supplies covered only under the medical benefit, see auto-immune infusions below
     
  • Prescription drugs obtained from a Preferred retail pharmacy, that are billed by a skilled nursing facility, nursing home, or extended care facility, see page 99

You Pay
Preferred professional providers and facilities: 30% of the Plan allowance (deductible applies)

Non-preferred professional providers (Participating/Non-participating) and Non-preferred facilities (Member/Non-member): You pay all charges
 
Benefit Description
Auto-immune infusion medications: Remicade, Renflexis and Inflectra

Note: 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).

You Pay
Preferred professional providers and facilities: 30% of the Plan allowance (deductible applies)

Non-preferred professional providers (Participating/Non-participating) and Non-preferred facilities (Member/Non-member): You pay all charges