2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 111
Section 5(f). Prescription Drug Benefits
Page 111
Note: 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.
Note: See Section 5(a) Medical Supplies for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube under the medical benefit.
Note: See Section 5(a) Medical Supplies 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.
Note: Pharmacies within our network for prescription drugs are not necessarily Preferred for durable medical equipment (DME) and medical supplies. To receive Preferred benefits for DME and covered medical supplies, you must use a Preferred DME or medical supply provider. See Section 5(a) for the benefit levels that apply to DME and medical supplies.
Note: For prescription drugs billed by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on the following pages for drugs obtained from a pharmacy in our network, as long as the pharmacy supplying the prescription drugs to the facility is a network pharmacy.
- Make sure you have your Plan 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.
Note: Pharmacies within our network for prescription drugs are not necessarily Preferred for durable medical equipment (DME) and medical supplies. To receive Preferred benefits for DME and covered medical supplies, you must use a Preferred DME or medical supply provider. See Section 5(a) for the benefit levels that apply to DME and medical supplies.
Note: For prescription drugs billed by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on the following pages for drugs obtained from a pharmacy in our network, as long as the pharmacy supplying the prescription drugs to the facility is a network pharmacy.
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.
Under Standard Option, this separate catastrophic maximum is $2,000
Under Basic Option, this separate catastrophic maximum is $3,250.
This amount accumulates toward the out-of-pocket catastrophic protection maximums 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.
Under Standard Option, this separate catastrophic maximum is $2,000
Under Basic Option, this separate catastrophic maximum is $3,250.
This amount accumulates toward the out-of-pocket catastrophic protection maximums described in Section 4 for combined medical and drug expenses for those not enrolled under the FEP Medicare Prescription Drug Program.
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.
Benefit Description
Covered Medication and Supplies
Retail Pharmacies
Covered drugs and supplies, such as:
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 30-day supply ($15 copayment for a 31 to 90-day supply) (no deductible)
Tier 2 (preferred brand-name drug): 15% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 4 (preferred specialty drug): $60 copayment for each purchase of up to a 30-day supply ($170 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $10 copayment for each purchase of up to a 30-day supply ($30 copayment for a 31 to 90-day supply)
Tier 2 (preferred brand-name drug): $45 copayment for each purchase of up to a 30-day supply ($135 copayment for a 31 to 90-day supply)
Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance ($60 minimum) for each purchase of up to a 30-day supply ($175 minimum for a 31 to 90-day supply)
Benefit Description
Covered Medication and Supplies
Retail Pharmacies
Covered drugs and supplies, such as:
- Drugs, vitamins and minerals, and nutritional supplements that by Federal law of the United States require a prescription for their purchase
- Drugs for the diagnosis and treatment of infertility
- Drugs for IVF – limited to 3 cycles annually (prior approval required)
Note: Drugs used for IVF must be purchased through the pharmacy drug program and you must meet our definition of infertility.
- Drugs associated with covered artificial insemination procedures
- Drugs to treat gender dysphoria (gonadotropin releasing hormone (GnRH) antagonists and testosterones)
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 30-day supply ($15 copayment for a 31 to 90-day supply) (no deductible)
Tier 2 (preferred brand-name drug): 15% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 4 (preferred specialty drug): $60 copayment for each purchase of up to a 30-day supply ($170 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $10 copayment for each purchase of up to a 30-day supply ($30 copayment for a 31 to 90-day supply)
Tier 2 (preferred brand-name drug): $45 copayment for each purchase of up to a 30-day supply ($135 copayment for a 31 to 90-day supply)
Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance ($60 minimum) for each purchase of up to a 30-day supply ($175 minimum for a 31 to 90-day supply)