2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 103
Section 5(f). Prescription Drug Benefits
Page 103
Section 5(f). Prescription Drug Benefits
Important things you should keep in mind about these benefits:
- We cover prescription drugs and supplies, as described in the chart beginning on page 108.
- 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 tier cost-share plus the difference in the cost of the brand-name and generic drug. If the provider’s prescription is for the brand-name drug and indicates “dispense as written,” you are responsible only for the applicable tier cost-share.
- 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 pages 114-115 for Tier 4 and Tier 5 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, pages 119-120, 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, the Mail Service Prescription Drug Program, 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
- Mail Service Prescription Drug Program: 800-262-7890, 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 refer to pages 106-107 for more information about the PSQM program and 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) to Tier 3 (non-preferred brand-name) if a generic equivalent becomes available or if new safety concerns arise. We may also move a specialty drug from Tier 4 (preferred) to Tier 5 (non-preferred) if a generic equivalent or biosimilar becomes available or if new safety concerns arise. If your drug is moved to a higher tier, your cost-share will increase. See pages 114-116 for the amounts members pay for Preferred retail, mail service, and specialty drug purchases. 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.
- The Standard Option and Basic Option formularies both contain a comprehensive list of drugs under all therapeutic categories with two exceptions: some drugs, nutritional supplements and supplies are not covered (see pages 118-119); we may also exclude certain U.S. FDA-approved drugs when multiple generic equivalents/alternative medications are available. See pages 104 and 105 for details.