2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 105
Section 5(f). Prescription Drug Benefits
Page 105
• What is covered.
Under Basic Option, we use a managed formulary for certain drug classes. If you purchase a drug in a class included in the managed formulary that is not on the managed formulary, you will pay the full cost of that drug since that drug is not covered under your benefit.
Under Standard Option and Basic Option
Note: Both formularies include lists of preferred drugs that are safe, effective and appropriate for our members, and are available at lower costs than non-preferred drugs. If your physician prescribed a more expensive non-preferred drug for you, we may ask that he or she prescribe a preferred drug instead; we encourage you to do the same. If you purchase a drug that is not on our preferred drug list, your cost will be higher. Your cooperation with our cost-savings efforts helps keep your premium affordable.
Note: 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. If you purchase a drug, nutritional supplement, or supply that is not covered, you will be responsible for the full cost of the item.
Note: Before filling your prescription, please check the preferred/non-preferred status of the drug. Other than changes resulting from new drugs or safety issues, the preferred drug list is updated periodically during the year. Changes to the preferred drug list are not considered benefit changes.
Note: 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 drugs will provide you with a high-quality, cost-effective prescription drug benefit.
Our payment levels are generally categorized as:
Tier 1: Includes generic drugs
Tier 2: Includes preferred brand-name drugs
Tier 3: Includes non-preferred brand-name drugs
Tier 4: Includes preferred specialty drugs
Tier 5: Includes non-preferred specialty drugs
You can view both the Standard Option and Basic Option formularies, which include the preferred drug list for each, on our website at www.fepblue.org or call 800-624-5060, TTY: 711, for assistance. 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.
Under Basic Option, we use a managed formulary for certain drug classes. If you purchase a drug in a class included in the managed formulary that is not on the managed formulary, you will pay the full cost of that drug since that drug is not covered under your benefit.
Under Standard Option and Basic Option
Note: Both formularies include lists of preferred drugs that are safe, effective and appropriate for our members, and are available at lower costs than non-preferred drugs. If your physician prescribed a more expensive non-preferred drug for you, we may ask that he or she prescribe a preferred drug instead; we encourage you to do the same. If you purchase a drug that is not on our preferred drug list, your cost will be higher. Your cooperation with our cost-savings efforts helps keep your premium affordable.
Note: 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. If you purchase a drug, nutritional supplement, or supply that is not covered, you will be responsible for the full cost of the item.
Note: Before filling your prescription, please check the preferred/non-preferred status of the drug. Other than changes resulting from new drugs or safety issues, the preferred drug list is updated periodically during the year. Changes to the preferred drug list are not considered benefit changes.
Note: 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 drugs will provide you with a high-quality, cost-effective prescription drug benefit.
Our payment levels are generally categorized as:
Tier 1: Includes generic drugs
Tier 2: Includes preferred brand-name drugs
Tier 3: Includes non-preferred brand-name drugs
Tier 4: Includes preferred specialty drugs
Tier 5: Includes non-preferred specialty drugs
You can view both the Standard Option and Basic Option formularies, which include the preferred drug list for each, on our website at www.fepblue.org or call 800-624-5060, TTY: 711, for assistance. 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 retail pharmacy, through the Specialty Drug Pharmacy Program, or, for Standard Option members and for Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program, you authorize the pharmacist to substitute any available U.S. FDA approved generic equivalent, unless you or your physician specifically requests a brand-name drug and indicates “dispense as written.” Keep in mind that Basic Option members must use Preferred providers in order to receive benefits. See Section 10, Definitions, page 154, for more information about generic alternatives and 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 retail pharmacy, through the Specialty Drug Pharmacy Program, or, for Standard Option members and for Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program, you authorize the pharmacist to substitute any available U.S. FDA approved generic equivalent, unless you or your physician specifically requests a brand-name drug and indicates “dispense as written.” Keep in mind that Basic Option members must use Preferred providers in order to receive benefits. See Section 10, Definitions, page 154, 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.