The formulary is a covered drug list. It’s comprised of generic, brand name and specialty drugs. Drugs on the formulary are assigned to a tier. Your out-of-pocket cost will depend on the tier your drug is in. Formulary placement decisions are based on recommendations by the Pharmacy and Medical Policy Committee (PMPC) – an independent group of practicing physicians and pharmacists. You can view the formularies on our Formulary page.
Your out-of-pocket cost is based on the tier your drug is in. Standard and Basic Option have five drug tiers:
Tier 1 - Generic drugs
Tier 2 - Preferred brand name drugs
Tier 3 - Non-preferred brand name drugs
Tier 4 - Preferred specialty drugs
Tier 5 - Non-preferred specialty drugs
FEP Blue Focus has two drug tiers:
Tier 1 - Preferred generics
Tier 2 - Preferred brand name drugs, Preferred generic specialty drugs, and Preferred brand name specialty drugs
Basic Option has a managed formulary. This means that we cover most U.S. FDA approved drugs. See the Managed Not Covered list with available covered options.
FEP Blue Focus has a limited (or closed) formulary. This means that we only cover some U.S. FDA approved drugs. Drugs not on the FEP Blue Focus formulary are generally not covered.
Certain drugs are not covered under Basic Option. These drugs, known as “Managed Not Covered” drugs, have other drugs available that treat the same condition—either generic drugs, brand name drugs or both. These options are effective and safe, and they may help you save money on your prescriptions. Click here for a full listing of “Managed Not Covered” drugs and available covered options. Basic Option members taking a “Managed Not Covered” drug should expect to pay the full cost of the prescription.
A few drugs are not covered on the Standard Option formulary. These “Excluded” drugs have other drugs available that treat the same condition—either generic drugs, brand name drugs or both. These options are effective and safe, and they may help you save money on your prescriptions. Click here for a full listing of excluded drugs and available covered options. Standard Option members taking an excluded drug should expect to pay the full cost of the prescription.
A generic drug has the same active ingredient and dosage form (e.g. tablet or capsule), and works in exactly the same way as its brand name counterpart. When the patent on a brand name drug expires, other drug manufacturers can apply to the U.S. Food and Drug Administration (FDA) to make a generic version of the drug. The FDA approves generic drugs when manufacturers have proven that the generic version is as safe and effective as the brand name counterpart. Generic drugs usually cost less than the brand name equivalent. Therefore, using generic drugs instead of brand name drugs is one of the easiest ways to reduce your prescription costs.
There are two ways to find out if the brand name drug you are taking is available in generic form. You can use the check drug cost tool to search for a brand name drug and see if it has any generic equivalents. You can also contact the Retail, Mail Service or Specialty drug programs at the following toll-free numbers and a customer service representative will help you.
Specialty drugs are drugs that are typically high in cost and include one or more of the following characteristics:
Injectable, infused, inhaled
Products of biotechnology
Require special handling, shipping and storage
Involve specialized patient training and coordination of care
You can download the specialty drug list here. This list is reviewed and updated regularly.
Drug prior approval is a process to obtain advanced approval of coverage for a prescription drug. Most drugs are covered without requiring prior approval. However, some select drugs require your doctor to provide information about your prescription to determine coverage. You can see the full list of prescription drugs that need to be approved here.
Your doctor can submit prior approval electronically, by fax or by mail. Forms and additional information can be downloaded here.
Preferred retail pharmacy means a pharmacy has an agreement with CVS Caremark to provide covered services to our members. You can choose from more than 57,000 network pharmacies nationwide when filling your prescriptions.
Standard Option members can purchase prescription drugs and supplies from a Non-preferred pharmacy but will have to pay the full amount for these items when they are filled. Then, you will have to file a Retail Prescription Drug claim form for reimbursement.
Basic Option members and FEP Blue Focus members cannot use their pharmacy benefit at Non-preferred retail pharmacies. You will pay the full cost of the drug if you visit a pharmacy outside of the network.
To make sure you are getting the best value check the cost of your prescription drugs by using the check drug cost tool.
You can also contact Customer Care at the following toll-free numbers and a customer service representative will help you.
Please refer to the Overseas FAQ page where you will find all FAQs related to using your pharmacy benefits while overseas.