FEP Medicare Prescription Drug Program (MPDP)
A Medicare prescription drug benefit for eligible members who qualify for Medicare Part A and/or Medicare Part B utilizing Medicare as their Primary Health Care coverage.
MPDP Resources by Plan
FEP Blue Focus Evidence of Coverage (EOC)
View instructions on how to get your prescriptions drugs, your rights and responsibilities and more.
2025 Evidence of Coverage (English)
2024 Evidence of Coverage (English)
FEP Blue Focus Summary of Benefits
View of summary of MPDP benefits for FEP Blue Focus.
2025 Summary of Benefits (English)
FEP Blue Focus MPDP Formulary
View the approved drug list under the MPDP drug tiers.
FEP Blue Focus Prior Approval MPDP Criteria
Some medications require prior approval before coverage is provided.
2025 Prior Approval MPDP Criteria (English)
2025 Prior Approval MPDP Criteria (Spanish)
2024 Prior Approval MPDP Criteria (English)
2024 Prior Approval MPDP Criteria (Spanish)
Step Therapy Criteria
Some medications may require a previous use of one or more drugs before coverage is provided.
2025 Step Therapy Criteria (English)
2025 Step Therapy Criteria (Spanish)
Annual Notice of Change
View changes to your plan's coverage, costs and more.
FEP Blue Basic Evidence of Coverage (EOC)
View instructions on how to get your prescriptions drugs, your rights and responsibilities and more.
2025 Evidence of Coverage (English)
2024 Evidence of Coverage (English)
FEP Blue Basic Summary of Benefits
View of summary of MPDP benefits for FEP Blue Basic.
2025 Summary of Benefits (English)
FEP Blue Basic MPDP Formulary
View the approved drug list under the MPDP drug tiers.
FEP Blue Basic Prior Approval MPDP Criteria
Some medications require prior approval before coverage is provided.
2025 Prior Approval MPDP Criteria (English)
2025 Prior Approval MPDP Criteria (Spanish)
2024 Prior Approval MPDP Criteria (English)
2024 Prior Approval MPDP Criteria (Spanish)
Step Therapy Criteria
Some medications may require a previous use of one or more drugs before coverage is provided.
2025 Step Therapy Criteria (English)
2025 Step Therapy Criteria (Spanish)
Annual Notice of Change
View changes to your plan's coverage, costs and more.
FEP Blue Standard Evidence of Coverage (EOC)
View instructions on how to get your prescriptions drugs, your rights and responsibilities and more.
2025 Evidence of Coverage (English)
FEP Blue Standard Summary of Benefits
View of summary of MPDP benefits for FEP Blue Standard.
2025 Summary of Benefits (English)
FEP Blue Standard MPDP Formulary
View the approved drug list under the MPDP drug tiers.
FEP Blue Standard Prior Approval MPDP Criteria
Some medications require prior approval before coverage is provided.
2025 Prior Approval MPDP Criteria (English)
2025 Prior Approval MPDP Criteria (Spanish)
2024 Prior Approval MPDP Criteria (English)
2024 Prior Approval MPDP Criteria (Spanish)
Step Therapy Criteria
Some medications may require a previous use of one or more drugs before coverage is provided.
2025 Step Therapy Criteria (English)
2025 Step Therapy Criteria (Spanish)
Annual Notice of Change
View changes to your plan's coverage, costs and more.
Your Explanation of Benefits (EOB)
Each month you fill a prescription, we'll mail you an "Explanation of Benefits" (EOB). This notice gives you a summary of your prescription drug claims and costs.
MPDP Materials
MPDP Pharmacy Directory
View the network of pharmacies where you can fill your prescriptions.
Prescription Drug Transition Policy
Income-Related Monthly Adjustment Amount (IRMAA)
View information about Income-Related Monthly Adjustment Amount (IRMAA).
Enhanced Prior Approval Criteria
Additional drug coverage under this enhanced benefit may require prior approval before coverage is provided. View the list below for more information.
2025 Enhanced Prior Approval Criteria (English)
2025 Enhanced Prior Approval Criteria (Spanish)
Appeal Request
If we have denied coverage or payment for a drug under your Medicare Part D benefit and you do not agree with our decision, you have the right to appeal the decision. View the document below for more information.
Mail Order Form
Use this form to request pharmacy prescriptions be mailed to you.
MPDP Disenrollment Form
Use this form to disenroll from MPDP. Mail the completed form to FEP Medicare Prescription Drug Program, PO Box 3539, Scranton, PA 18505 or fax to 855-865-1817.
MPDP Claim Form
Use this form to submit your MPDP prescription claims via mail. Mail the completed form with receipts to CVS Caremark Medicare Part D Processing, P.O. Box 52066, Phoenix, AZ 85072-2066.
MPDP Utilization Management Forms
Formulary Exception Form
Use this form to request coverage of a drug that is not on your formulary. To process this request, your physician must provide a supporting statement documenting that all formulary alternatives would not be as effective or would have adverse effects.
Tier Exception Form
Use this form to request coverage of a brand or generic in a higher cost tier at a lower cost tier. Certain restrictions apply. To process this request, your physician must provide a supporting statement documenting that all of the drugs to treat the same medical condition on the lower cost tier would not be as effective or would have adverse effects.
Quantity Limit Exception Form
Use this form to request coverage of a quantity in excess of plan quantity limits. To process this request, your physician must provide a supporting statement explaining why the quantity allowed would not be as effective or would have adverse effects.
Step Therapy Exception Form
Use this form to request an exception to the plan step therapy requirement. Step therapy drugs are formulary drugs that are covered only if certain formulary alternatives have been tried first. To process this request, your physician must provide a supporting statement documenting that Step 1 medications have been tried or are likely to cause adverse effects.
Part D Model Coverage Determination and Redetermination Request Forms
Coverage Determination (Prior Authorization) Request Form
Use this form to request a coverage determination for a medication. Coverage determinations are inclusive of all types of requests that can be made regarding drug coverage, such as prior authorizations, exceptions, and reimbursement.
Redetermination Form
If your request for coverage of (or payment for) a prescription drug is denied, you have the right to ask for a redetermination (appeal) of the decision. You may use this form to request an appeal of this decision.
CMS Appointment of Representative Form (CMS Form-1696)
If you’re in MPDP and would like to appoint a person to file a grievance, request a coverage determination or request an appeal on your behalf, you and the person accepting the appointment must fill out this form and submit it with your request. Your prescribing physician or other prescriber may request a coverage determination, redetermination or IRE reconsideration on your behalf without having to be an appointed representative.
If you’re a member of MPDP or a physician and have questions about process or status, you can call 1-800-MEDICARE.
To view a Notice of Privacy Practices as required under the HIPAA Privacy Rule (45 CFR 164.520) click here.
Have a question about MPDP?
If you have a question, you can call 1-888-338-7737 (TTY: 711). Available 24 hours a day, 365 days a year.
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