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2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 109

We will send each new enrollee a Plan identification card, which covers pharmacy and medical benefits.

There are important features you should be aware of. These include:

Who can write your prescriptions. A physician or dentist licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, or, in states that permit it, a licensed/certified provider with prescriptive authority prescribing within their scope of practice must write your prescriptions.

Where you can obtain them.

Under Standard Option and Basic Option, you may fill prescriptions at a pharmacy that participates in our nationwide network. The network includes retail pharmacies, mail service pharmacies and specialty pharmacies. You may also receive your medication from a long-term care pharmacy when your care is handled in or by a long-term care facility. You will receive a copy of the pharmacy directory, which lists all pharmacies participating in our network, in your enrollment package. You may also go online to our webpage www.fepblue.org/medicarerx/resources for a complete listing.

Note: Due to manufacturer restrictions, a small number of specialty drugs used to treat rare or uncommon conditions may be available only through select pharmacies in our network.

What is covered.

Under Standard Option and Basic Option

Both formularies include lists of preferred drugs that are safe, effective and appropriate for our members, and are available at lower costs than non-preferred drugs. If you purchase a drug that is not on our preferred drug list, your cost will be higher. Your cooperation with our cost-savings efforts helps keep your premium affordable.

Note: Member cost-share for prescription drugs is determined by the tier to which a drug has been assigned. To determine the tier assignments for formulary drugs, we work with the CVS Caremark National Pharmacy and Therapeutics Committee, a group of physicians and pharmacists who are not employees or agents of, nor have any financial interest in the Blue Cross and Blue Shield Service Benefit Plan. The committee meets quarterly to review new and existing drugs to assist us in our assessment.

Our payment levels are generally categorized as:

Tier 1: Includes generic drugs
Tier 2: Includes preferred brand-name drugs
Tier 3: Includes non-preferred brand-name drugs
Tier 4: Includes preferred specialty drugs

You can view both the Standard Option and Basic Option formularies, which include the preferred drug list for each, on our website at www.fepblue.org or call 888-338-7737, TTY: 711, for assistance. Changes to the formulary are not considered benefit changes.

Generic equivalents

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.

Disclosure of information. As part of our administration of prescription drug benefits, we may disclose information about your prescription drug utilization, including the names of your prescribing physicians, to any treating physicians or dispensing pharmacies.

These are the dispensing limitations.

Standard Option and Basic Option: Subject to manufacturer packaging and your prescriber’s instructions, you may purchase up to a 90-day supply of covered drugs and supplies through the pharmacy network.

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