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