2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 102
Section 5(f). Prescription Drug Benefits
Page 102
Prior Approval
As part of our Patient Safety and Quality Monitoring (PSQM) program, 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, 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 us using any of the numbers listed in the beginning of this section.
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 us using any of the numbers listed in the beginning of this section.
Medical Foods
The Plan covers medical food formulas and enteral nutrition products that are ordered by a healthcare provider and are medically necessary to prevent clinical deterioration in members at nutritional risk.
To receive benefits, products must meet the definition of medical food (See Section 10, Definitions).
Members must be receiving active, regular, and ongoing medical supervision and must be unable to manage the condition by modification of diet alone.
Coverage is provided as follows:
Note: A prescription and prior approval are required for medical foods provided under the pharmacy benefit. Renewals of the prior authorization are required every benefit year for inborn errors of metabolism and tube feeding.
Note: See Section 5(a), Medical Supplies, for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube under the medical benefit.
The Plan covers medical food formulas and enteral nutrition products that are ordered by a healthcare provider and are medically necessary to prevent clinical deterioration in members at nutritional risk.
To receive benefits, products must meet the definition of medical food (See Section 10, Definitions).
Members must be receiving active, regular, and ongoing medical supervision and must be unable to manage the condition by modification of diet alone.
Coverage is provided as follows:
- Inborn errors of amino acid metabolism
- Food allergy with atopic dermatitis, gastrointestinal symptoms, IgE mediation, malabsorption disorder, seizure disorder, failure to thrive, or prematurity, when administered orally and is the sole source (100%) of nutrition. This once per lifetime benefit is limited to one year following the date of the initial prescription or physician order for the medical food (e.g., Neocate, in a formula form or powders mixed to become formulas)
- Medical foods and nutritional supplements when administered by catheter or nasogastric tubes
Note: A prescription and prior approval are required for medical foods provided under the pharmacy benefit. Renewals of the prior authorization are required every benefit year for inborn errors of metabolism and tube feeding.
Note: See Section 5(a), Medical Supplies, for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube under the medical benefit.