2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 7. Filing a Claim for Covered Services
Page 137
Section 7. Filing a Claim for Covered Services
Page 137
If we need an extension because we have not received necessary information (e.g., medical records) from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.
If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.
Prescription drug claims
Preferred Retail Pharmacies – When you use Preferred retail pharmacies, show your Service Benefit Plan ID card. To find a Preferred retail pharmacy, visit www.fepblue.org/provider. If you use a Preferred retail pharmacy that offers online ordering, have your ID card ready to complete your purchase. Preferred retail pharmacies file your claims for you. We reimburse them for your covered drugs and supplies. You pay the applicable coinsurance or copayment.
Note: Even if you use Preferred retail pharmacies, you will have to file a paper claim form to obtain reimbursement if:
See the following paragraphs for claim filing instructions.
Non-preferred Retail Pharmacies
Standard Option: You must file a paper claim for any covered drugs or supplies you purchase at Non-preferred retail pharmacies. Contact your Local Plan or call 800-624-5060 to request a retail prescription drug claim form to claim benefits. Hearing-impaired members with TTY equipment may call 711. Follow the instructions on the prescription drug claim form and submit the completed form to: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057.
Basic Option: There are no benefits for drugs or supplies purchased at Non-preferred retail pharmacies.
Mail Service Prescription Drug Program
Eligible members: We will send you information on our Mail Service Prescription Drug Program, including an initial mail order form. To use this program:
Alternatively, your physician may call in your initial prescription at 800-262-7890, TTY: 711. You are responsible for the copayment. You are also responsible for the copayments for refills ordered by your physician.
After that, to order refills either call the same phone number or access our website at www.fepblue.org and either charge your copayment to your credit card or have it billed to you later. Allow up to ten days for delivery on refills.
Note: Specialty drugs will not be dispensed through the Mail Service Prescription Drug Program. See Section 5(f) for information about the Specialty Drug Pharmacy Program.
Basic Option: The Mail Service Prescription Drug Program is available only to members with primary Medicare Part B coverage under Basic Option.
If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.
Prescription drug claims
Preferred Retail Pharmacies – When you use Preferred retail pharmacies, show your Service Benefit Plan ID card. To find a Preferred retail pharmacy, visit www.fepblue.org/provider. If you use a Preferred retail pharmacy that offers online ordering, have your ID card ready to complete your purchase. Preferred retail pharmacies file your claims for you. We reimburse them for your covered drugs and supplies. You pay the applicable coinsurance or copayment.
Note: Even if you use Preferred retail pharmacies, you will have to file a paper claim form to obtain reimbursement if:
- You do not have a valid Service Benefit Plan ID card;
- You do not use your valid Service Benefit Plan ID card at the time of purchase; or
- You did not obtain prior approval when required (see Section 3).
See the following paragraphs for claim filing instructions.
Non-preferred Retail Pharmacies
Standard Option: You must file a paper claim for any covered drugs or supplies you purchase at Non-preferred retail pharmacies. Contact your Local Plan or call 800-624-5060 to request a retail prescription drug claim form to claim benefits. Hearing-impaired members with TTY equipment may call 711. Follow the instructions on the prescription drug claim form and submit the completed form to: Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057.
Basic Option: There are no benefits for drugs or supplies purchased at Non-preferred retail pharmacies.
Mail Service Prescription Drug Program
Eligible members: We will send you information on our Mail Service Prescription Drug Program, including an initial mail order form. To use this program:
- Complete the initial mail order form;
- Enclose your prescription and copayment;
- Mail your order to CVS Caremark, P.O. Box 1590, Pittsburgh, PA 15230-1590; and
- Allow up to two weeks for delivery.
Alternatively, your physician may call in your initial prescription at 800-262-7890, TTY: 711. You are responsible for the copayment. You are also responsible for the copayments for refills ordered by your physician.
After that, to order refills either call the same phone number or access our website at www.fepblue.org and either charge your copayment to your credit card or have it billed to you later. Allow up to ten days for delivery on refills.
Note: Specialty drugs will not be dispensed through the Mail Service Prescription Drug Program. See Section 5(f) for information about the Specialty Drug Pharmacy Program.
Basic Option: The Mail Service Prescription Drug Program is available only to members with primary Medicare Part B coverage under Basic Option.