Section 5(f). MPDP Overview

2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(f). Prescription Drug Benefits

FEP MEDICARE PRESCRIPTION DRUG PROGRAM

Important things you should keep in mind about these benefits for members enrolled in our (Medicare Part D), FEP Medicare Prescription Drug Program:

We cover prescription drugs and supplies, as detailed on the following pages for members enrolled in our FEP Medicare Prescription Drug Program.
Members with Medicare Part A and/or Part B primary are eligible for the benefits under the FEP Medicare Prescription Drug Program.
If you were originally group enrolled and chose to disenroll prior to January 1, 2024, you will not be able to rejoin the FEP Medicare Prescription Drug Program until the next enrollment period.
If you opt-out from the group enrollment or disenroll any time after January 1, 2024, you will not be eligible to re-enroll prior to the next enrollment period.
For additional information about who is eligible for this program and when, or to dispute your claim, please visit us at www.fepblue.org/medicarerx
We may provide additional coverage for prescription drugs not included in your Medicare Part D benefit. For more information about your share of the cost or which prescription drugs may or may not be covered, please call 888-338-7737, TTY 711.
If there is no generic drug available, you must pay the brand-name cost-sharing amount when you receive a brand-name drug.
Members enrolled in the FEP Medicare Prescription Drug program have no coverage for drugs obtained and/or purchased overseas.
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.
Certain medications may be covered under Medicare Part B or Medicare Part D, depending on the condition being treated.
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 pharmacies in our network. Review purchasing options for your prescriptions to get the best price. A drug cost tool is available at www.fepblue.org/medicarerx or call 888-338-7737, TTY: 711
YOU MUST GET PRIOR APPROVAL FOR CERTAIN DRUGS AND SUPPLIES, and prior approval must be renewed periodically. 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. If your drug is moved to a higher tier, your cost-share will increase. 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; we may also exclude certain U.S. FDA-approved drugs when multiple generic equivalents/alternative medications are available. See Not Covered later in this section for details.