2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f)(a). FEP Medicare Prescription Drug Plan
Page 112
Section 5(f)(a). FEP Medicare Prescription Drug Plan
Page 112
- A generic equivalent will be dispensed if it is available unless your physician specifically requires a brand name drug. If you receive a brand name drug when an FDA approved generic drug is available, and your physician has not specified Dispense as Written for the brand name drug, you have to pay the difference in cost between the brand name drug and the generic.
- Why use generic drugs. 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 pharmacy participating in our network, 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.” See Section 10, Definitions, for more information about generic alternatives and generic equivalents.
How to obtain your Prescription Drugs and Supplies.
Note: Pharmacies within our network for prescription drugs are not necessarily Preferred for durable medical equipment (DME) and medical supplies. To receive Preferred benefits for DME and covered medical supplies, you must use a Preferred DME or medical supply provider. See Section 5(a) for the benefit levels that apply to DME and medical supplies.
Note: For prescription drugs billed by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on the following pages for drugs obtained from a pharmacy in our network, as long as the pharmacy supplying the prescription drugs to the facility is a network pharmacy.
- Make sure you have your Plan ID card when you are ready to purchase your prescription.
- Go to any network pharmacy, or
- Visit the website of your retail pharmacy to request your prescriptions online and delivery, if available.
Note: Pharmacies within our network for prescription drugs are not necessarily Preferred for durable medical equipment (DME) and medical supplies. To receive Preferred benefits for DME and covered medical supplies, you must use a Preferred DME or medical supply provider. See Section 5(a) for the benefit levels that apply to DME and medical supplies.
Note: For prescription drugs billed by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on the following pages for drugs obtained from a pharmacy in our network, as long as the pharmacy supplying the prescription drugs to the facility is a network pharmacy.
- 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:
- 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 is required for medical foods provided under the pharmacy benefit.
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.
- When you do have to file a claim. Go to Section 7, How to file a prescription drug claim.
- If we deny your claim and you want to appeal, you, your representative, or your prescriber must request an appeal following the process described in Section 8(a). FEP Medicare Prescription Drug Plan Disputed Claims Process. The FEP Medicare Prescription Drug Plan appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll get instructions in the decision letter on how to move to the next level of appeal.