2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 107
Section 5(f). Prescription Drug Benefits
Page 107
- 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 and Prevention, American Medical Association, etc.), and manufacturer guidelines.
Prior Approval
As part of our Patient Safety and Quality Monitoring (PSQM) program (see page 106), you must make sure that 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. 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. 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: 711. 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.
Please note that 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.
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.
Note: 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.
As part of our Patient Safety and Quality Monitoring (PSQM) program (see page 106), you must make sure that 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. 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. 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: 711. 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.
Please note that 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.
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.
Note: 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.
Standard Option Generic Incentive Program
Your cost-share will be waived for the first 4 generic prescriptions filled (and/or refills ordered) per drug if you purchase a brand-name drug on the Generic Incentive Program List while a member of the Service Benefit Plan and then change to a corresponding generic drug replacement while still a member of the Plan.
Note: The list of eligible generic drug replacements may change and is not considered a benefit change. For the most up-to-date information, please visit www.fepblue.org/en/benefit-plans/coverage/pharmacy/generic-incentive-program 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
Your cost-share will be waived for the first 4 generic prescriptions filled (and/or refills ordered) per drug if you purchase a brand-name drug on the Generic Incentive Program List while a member of the Service Benefit Plan and then change to a corresponding generic drug replacement while still a member of the Plan.
- If you switch from one generic drug to another, you will be responsible for your copayment.
Note: The list of eligible generic drug replacements may change and is not considered a benefit change. For the most up-to-date information, please visit www.fepblue.org/en/benefit-plans/coverage/pharmacy/generic-incentive-program 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