Frequently Asked Questions

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. FEP Blue Standard and FEP Blue Basic 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

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.

FEP Blue Basic 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 Standard has a comprehensive formulary. This means we cover almost all U.S. FDA approved drugs. There is a small list of excluded drugs that are not covered. See the list of Excluded Drugs with available covered options.

With the FEP Medicare Prescription Drug Program (MPDP), there are four drug tiers for all of our plans. This benefit also offers additional approved prescription drugs in some tiers than our traditional pharmacy benefit. You can view MPDP formularies here. There is also an out-of-pocket maximum, or cap, on the amount you pay out-of-pocket on prescriptions annually.

Certain drugs are not covered under FEP Blue Basic. 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. FEP Blue Basic 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 FEP Blue Standard 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. FEP Blue Standard 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.

• Retail 1-800-624-5060
• Mail Service 1-800-262-7890
• Specialty 1-888-346-3731

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.

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 55,000 network pharmacies nationwide when filling your prescriptions.

To locate a Preferred retail pharmacy, click on Find a Pharmacy or call toll-free 1-800-624-5060.

FEP Blue Standard 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.

FEP Blue Basic 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.

• Retail 1-800-624-5060
• Mail Service 1-800-262-7890
• Specialty  1-888-346-3731

Please refer to the Overseas FAQ page where you will find all FAQs related to using your pharmacy benefits while overseas.

We regularly evaluate the usage and costs of prescription medications. We’ve found that the rapid increase in the use of weight loss GLP-1s is the main factor increasing costs. To maintain our prescription drug program, plan premiums and access to weight loss medications, tier adjustments were necessary. This is why starting in 2025, you won't be able to continue getting your weight loss GLP-1 drug in the 2024 tier.

Yes, there are weight loss GLP-1 drugs that are no longer covered due to the 2025 tier change. Starting in 2025, Wegovy (semaglutide) will not be covered for FEP Blue Focus members.

Yes, you can still obtain a weight loss GLP-1 that is not covered or excluded. In order to do so, your healthcare provider must submit a formulary exception request on your behalf. If your case aligns with the formulary exception guidelines, approval for your weight loss GLP-1 will be granted. Please note that a formulary exception does not change your out-of-pocket costs. 

You or your provider can download the FEP Traditional Formulary Exception Form (for Traditional FEHB & PSHB) or FEP MPDP Formulary Exception Form (for MPDP FEHB & PSHB) to submit a request. Your provider can also call 1-877-727-3784 (for Traditional FEHB & PSHB) or 1-855-344-0930 (for MPDP FEHB & PSHB). In addition, your provider can request the formulary criteria. Please contact your provider for details.

If your formulary exception is approved, here is the breakdown of what tier your drug will be in for 2025 based on which BCBS FEP plan you have:

For FEP Blue Basic and FEP Blue Standard, Zepbound (tirzepatide) would be Tier 3 non-preferred. For FEP Blue Focus, Wegovy (semaglutide) and Zepbound (tirzepatide) would be Tier 2 Preferred.

Even if your GLP-1 gets approved, you cannot request a tier exception.

Approved formulary exceptions issued in 2024 will be recognized through their expiration date. This means the 2025 non-covered/excluded drug will be available at a network pharmacy to process at tier 3 (for FEP Blue Basic and FEP Blue Standard) and at tier 2 (for FEP Blue Focus).

Please discuss the other GLP-1 and weight loss medications on the formulary with your healthcare provider. If you and your provider decide that you must be on the non-covered/excluded weight loss GLP-1, please refer to the denial letter mailed to you and your provider that will explain your appeal rights and steps you may take.

Please discuss the other GLP-1 and weight loss medications on the formulary with your healthcare provider. If you and your provider decide that you must be on the non-covered/excluded weight loss GLP-1, your provider must request a new formulary exception to continue accessing your medication in 2025.