2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 119
Section 5(f). Prescription Drug Benefits
Page 119
Benefits Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Over-the-counter (OTC) contraceptive drugs and devices, except as previously described in this section
- Drugs used to terminate pregnancy
- Sublingual allergy desensitization drugs, except as described in Section 5(a)
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefits Description
Drugs From Other Sources
Covered prescription drugs and supplies not obtained at a retail pharmacy, through the Specialty Drug Pharmacy Program, or, for Standard Option members and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. This includes drugs and supplies covered only under the medical benefit.
Note: Prior approval is required for certain high-cost drugs obtained outside one of our pharmacy programs. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/highcostdrugs for a list of these drugs. See Section 3 for more information on prior approval.
Note: We cover drugs and supplies purchased overseas as shown here, as long as they are the equivalent to drugs and supplies that by Federal law of the United States require a prescription. Please refer to Section 5(i) for more information.
Note: For covered prescription drugs and supplies purchased outside of the United States, Puerto Rico, and the U.S. Virgin Islands, please submit claims on an Overseas Claim Form. See Section 5(i) for information on how to file claims for overseas services.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating professional provider: 35% of the Plan allowance (deductible applies)
Non-participating professional provider: 35% of the Plan allowance (deductible applies) plus any difference between our allowance and the billed amount
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: 30% of the Plan allowance
Participating professional provider: You pay all charges
Non-participating professional provider: You pay all charges
Member/Non-member facilities: You pay all charges
Drugs From Other Sources
Covered prescription drugs and supplies not obtained at a retail pharmacy, through the Specialty Drug Pharmacy Program, or, for Standard Option members and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. This includes drugs and supplies covered only under the medical benefit.
Note: Prior approval is required for certain high-cost drugs obtained outside one of our pharmacy programs. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/highcostdrugs for a list of these drugs. See Section 3 for more information on prior approval.
Note: We cover drugs and supplies purchased overseas as shown here, as long as they are the equivalent to drugs and supplies that by Federal law of the United States require a prescription. Please refer to Section 5(i) for more information.
Note: For covered prescription drugs and supplies purchased outside of the United States, Puerto Rico, and the U.S. Virgin Islands, please submit claims on an Overseas Claim Form. See Section 5(i) for information on how to file claims for overseas services.
- Please refer to the Sections indicated for additional benefit information related to drugs obtained from other sources:
- Physician’s office – Section 5(a)
- Facility (inpatient or outpatient) – Section 5(c)
- Hospice agency – Section 5(c)
- Physician’s office – Section 5(a)
- Please refer to information discussed previously in this section for prescription drugs obtained from a Preferred retail pharmacy, that are billed for by a skilled nursing facility, nursing home, or extended care facility.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating professional provider: 35% of the Plan allowance (deductible applies)
Non-participating professional provider: 35% of the Plan allowance (deductible applies) plus any difference between our allowance and the billed amount
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: 30% of the Plan allowance
Participating professional provider: You pay all charges
Non-participating professional provider: You pay all charges
Member/Non-member facilities: You pay all charges
Drugs From Other Sources - continued on next page