2024 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits
Page 94
Section 5(f). Prescription Drug Benefits
Page 94
- 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.
Catastrophic Maximums
Each individual enrolled in the FEP Medicare Prescription Drug Program has a separate and lower out-of-pocket catastrophic protection maximum for the drugs purchased while covered under this Program.
This separate catastrophic maximum is $3,250.
This amount accumulates toward the out-of-pocket catastrophic protection maximum described in Section 4 for combined medical and drug expenses for those not enrolled under the FEP Medicare Prescription Drug Program.
Each individual enrolled in the FEP Medicare Prescription Drug Program has a separate and lower out-of-pocket catastrophic protection maximum for the drugs purchased while covered under this Program.
This separate catastrophic maximum is $3,250.
This amount accumulates toward the out-of-pocket catastrophic protection maximum described in Section 4 for combined medical and drug expenses for those not enrolled under the FEP Medicare Prescription Drug Program.
Medical Foods
Medical foods, as defined by the U.S. Food and Drug Administration, that are consumed or administered enterally and are intended for the specific dietary management of a disease or condition for which there are distinctive nutritional requirements.
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.
Must meet the definition of medical food described in Section 10.
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:
Notes:
Medical foods, as defined by the U.S. Food and Drug Administration, that are consumed or administered enterally and are intended for the specific dietary management of a disease or condition for which there are distinctive nutritional requirements.
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.
Must meet the definition of medical food described in Section 10.
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
Notes:
- 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.
- See Section 5(a) for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube under the medical benefit.
Here is how to obtain your prescription drugs and supplies:
- Make sure you have your 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.