2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 113
Section 5(f). Prescription Drug Benefits
Page 113
Benefit Description
Covered Medication and Supplies (cont.)
Note: If the cost of your prescription is less than your copayment, you pay only the cost of your prescription. The Mail Service Prescription Drug Program will charge you the lesser of the prescription cost or the copayment when you place your order. If you have already sent in your copayment, they will credit your account with any difference.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $85 copayment (no deductible)
Tier 3 (non-preferred brands): $125 copayment (no deductible)
Tier 4 (specialty-drugs): $150 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $15 copayment
Tier 2 (preferred brand-name drug): $95 copayment
Tier 3 (non-preferred brands): $125 copayment
Tier 4 (specialty-drugs): $150 copayment
Covered Medication and Supplies (cont.)
Note: If the cost of your prescription is less than your copayment, you pay only the cost of your prescription. The Mail Service Prescription Drug Program will charge you the lesser of the prescription cost or the copayment when you place your order. If you have already sent in your copayment, they will credit your account with any difference.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $85 copayment (no deductible)
Tier 3 (non-preferred brands): $125 copayment (no deductible)
Tier 4 (specialty-drugs): $150 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $15 copayment
Tier 2 (preferred brand-name drug): $95 copayment
Tier 3 (non-preferred brands): $125 copayment
Tier 4 (specialty-drugs): $150 copayment
Benefit Description
Asthma Medications
Network Retail Pharmacies:
Note: See Section 3 for information about drugs and supplies that require prior approval.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): 10% of the Plan allowance (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
Tier 2 (preferred brand-name drug): $30 copayment for each purchase of up to a 30-day supply ($90 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program
Note: You must obtain prior approval for certain drugs before Mail Service will fill your prescription. See Section 3.
Note: See earlier in this section for Tier 3 and Tier 4 prescription drug benefits
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $65 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $75 copayment
Asthma Medications
Network Retail Pharmacies:
Note: See Section 3 for information about drugs and supplies that require prior approval.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): 10% of the Plan allowance (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
Tier 2 (preferred brand-name drug): $30 copayment for each purchase of up to a 30-day supply ($90 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program
Note: You must obtain prior approval for certain drugs before Mail Service will fill your prescription. See Section 3.
Note: See earlier in this section for Tier 3 and Tier 4 prescription drug benefits
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $65 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $75 copayment
Benefit Description
Other Preferred Diabetic Medications, Test Strips, and Supplies
Network Retail Pharmacies:
Standard Option - You Pay
Tier 2 (preferred diabetic medications and supplies): 10% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 2 (preferred insulins): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $30 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program:
Note: See earlier in this section for Tier 2, 3, and 4 prescription drug benefits.
Benefits will be provided for syringes, pens and pen needles and test strips at Tier 2 (diabetic medications and supplies) for those enrolled in the FEP Medicare Prescription Drug Program when obtained through the Mail Service Prescription Drug Program.
Standard Option - You Pay
Tier 2 (preferred brand-name drug): $40 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - You Pay
Tier 2 (preferred brand-name drugs): $50 copayment for each purchase of up to a 90-day supply
Other Preferred Diabetic Medications, Test Strips, and Supplies
Network Retail Pharmacies:
Standard Option - You Pay
Tier 2 (preferred diabetic medications and supplies): 10% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 2 (preferred insulins): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $30 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program:
Note: See earlier in this section for Tier 2, 3, and 4 prescription drug benefits.
Benefits will be provided for syringes, pens and pen needles and test strips at Tier 2 (diabetic medications and supplies) for those enrolled in the FEP Medicare Prescription Drug Program when obtained through the Mail Service Prescription Drug Program.
Standard Option - You Pay
Tier 2 (preferred brand-name drug): $40 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - You Pay
Tier 2 (preferred brand-name drugs): $50 copayment for each purchase of up to a 90-day supply
The pharmacy benefits starting here to the end of the section apply to all covered members, unless otherwise noted.