See how your Service Benefit Plan coverage works with different types of prescription drugs.
The formulary is a list of our covered prescription drugs, including generic, brand name and specialty drugs.
See how we help keep your out-of-pocket costs low for the medications you and your family need.
Eligible members with Medicare get lower out-of-pocket costs for higher cost drugs and additional approved prescription drugs in some tiers than the traditional pharmacy benefit.
We organize our covered prescription drugs into tiers. The amount you pay for a drug depends on the tier. In general, the lower the drug tier, the less you pay.
There are five drug tiers under the traditional pharmacy benefit for FEP Blue Basic™ and FEP Blue Standard™.
There are only two drug tiers under the traditional pharmacy benefit for FEP Blue Focus ® . There are four drug tiers under MPDP for all our plans.Our Prescription Drug Cost Tool lets you check drug costs 24/7. See if your drug is covered under your selected plan and compare costs of covered drugs for all three plans.
Tier 1 (Generics): $5 copay up to a 30-day supply; $15 copay for a 31 to 90-day supply
Tier 2 (Preferred brand): 40% of our allowance ($350 max) for up to a 30-day supply; $1,050 maximum for 31 to 90-day supply)
Tier 1 (Generics): $15 copay up to a 30-day supply; $40 copay for a 31 to 90-day supply
Tier 2 (Preferred brand): $60 copay for up to a 30-day supply; $180 copay for a 31 to 90-day supply
Tier 3 (Non-preferred brand): 60% of our allowance ($90 minimum) for up to a 30-day supply; $250 minimum for a 31 to 90-day supply)
Tier 4 (Preferred specialty): $85 copay
Tier 5 (Non-preferred specialty): $110 copay
Tier 4 and 5 specialty drugs are limited to a 30-day supply; only one fill allowed. All refills must be obtained from the Specialty Drug Pharmacy Program.
Tier 2 (Preferred specialty): 40% of our allowance ($350 maximum) for a 30-day supply; $1,050 maximum for 31 to 90-day supply
Tier 4 (Preferred specialty): $85 copay
Tier 5 (Non-preferred specialty): $110 copay
This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the Plan’s Federal brochures (FEP Blue Standard and FEP Blue Basic: RI 71-005; FEP Blue Focus: 71-017). All benefits are subject to the definitions, limitations, and exclusions set forth in the federal brochure.
To give prior approval, we need to confirm two things: 1. that you’re using the drug to treat something we cover and 2. that your healthcare provider prescribes it in a medically appropriate way.
Your healthcare provider can request prior approval electronically, by fax or by mail. The full list of drugs that need to be approved, prior approval forms and additional information can be downloaded here.
Specific drugs on the approved MPDP drug list require prior approval and/or have quantity limits. We have these policies for safety purposes. You can see drugs with prior approval criteria and step therapy criteria on the MPDP Drug List here. The full list of Prior approval MPDP Criteria and Step Therapy Criteria can be downloaded under MPDP Resources by Plan.
Your health care provider can request prior approval by contacting your local BCBS company. The full list of these select high-cost drugs can be downloaded here.
Our three plan options have certain drugs that are not covered on their formularies (approved drug lists). Each non-covered drug has safe and effective, alternative covered drug options. You can see the list of what’s not covered and available alternative options for FEP Blue Standard and FEP Blue Basic. FEP Blue Focus members can apply for coverage of a drug not covered on their formulary with the Non-Formulary Exception Process (NFE) form.
