2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 99
Section 5(f). Prescription Drug Benefits
Page 99
- Under Standard Option,
- You may use the Retail Pharmacy Program, the Mail Service Prescription Drug Program, or the Specialty Drug Pharmacy Program to fill your prescriptions.
- There is no calendar year deductible for the Retail Pharmacy Program, the Mail Service Prescription Drug Program, or the Specialty Drug Pharmacy Program.
- You may use the Retail Pharmacy Program, the Mail Service Prescription Drug Program, or the Specialty Drug Pharmacy Program to fill your prescriptions.
- Under Basic Option,
- You must use Preferred retail pharmacies or the Specialty Drug Pharmacy Program in order to receive benefits. Our specialty drug pharmacy is a Preferred pharmacy.
- The Mail Service Prescription Drug Program is available only to members with primary Medicare Part B coverage.
- There is no calendar year deductible.
- We use a managed formulary for certain drug classes.
- You must use Preferred retail pharmacies or the Specialty Drug Pharmacy Program in order to receive benefits. Our specialty drug pharmacy is a Preferred pharmacy.
We will send each new enrollee a Plan identification card, which covers pharmacy and medical benefits. Standard Option members, and Basic Option members with primary Medicare Part B coverage, are eligible to use the Mail Service Prescription Drug Program and will also receive a mail service order form and a pre-addressed reply envelope.
There are important features you should be aware of. These include:
• Who can write your prescriptions. A physician or dentist licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, or, in states that permit it, a licensed/certified provider with prescriptive authority prescribing within their scope of practice must write your prescriptions. See Section 5(i) for drugs purchased overseas.
• Where you can obtain them.
There are important features you should be aware of. These include:
• Who can write your prescriptions. A physician or dentist licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, or, in states that permit it, a licensed/certified provider with prescriptive authority prescribing within their scope of practice must write your prescriptions. See Section 5(i) for drugs purchased overseas.
• Where you can obtain them.
Under Standard Option, you may fill prescriptions at a Preferred retail pharmacy, at a Non-preferred retail pharmacy, through our Mail Service Prescription Drug Program, or through the Specialty Drug Pharmacy Program. Under Standard Option, we pay a higher level of benefits when you use a Preferred retail pharmacy, our Mail Service Prescription Drug Program, or the Specialty Drug Pharmacy Program.
Under Basic Option, you must fill prescriptions only at a Preferred retail pharmacy or through the Specialty Drug Pharmacy Program, in order to receive benefits. If Medicare Part B is your primary coverage, you may also fill prescriptions through our Mail Service Prescription Drug Program.
Under Standard Option and Basic Option
Note: Neither the Mail Service Prescription Drug Program nor the Specialty Drug Pharmacy Program will fill your prescription for a drug requiring prior approval until you have obtained prior approval. CVS Caremark, the program administrator, will hold your prescription for you up to 30 days. If prior approval is not obtained within 30 days, your prescription will be unable to be filled and a letter will be mailed to you explaining the prior approval procedures.
Note: Both Preferred and Non-preferred retail pharmacies may offer options for ordering prescription drugs online. Drugs ordered online may be delivered to your home; however, these online orders are not a part of the Mail Service Prescription Drug Program.
Note: Due to manufacturer restrictions, a small number of specialty drugs used to treat rare or uncommon conditions may be available only through a Preferred retail pharmacy.
Under Basic Option, you must fill prescriptions only at a Preferred retail pharmacy or through the Specialty Drug Pharmacy Program, in order to receive benefits. If Medicare Part B is your primary coverage, you may also fill prescriptions through our Mail Service Prescription Drug Program.
Under Standard Option and Basic Option
Note: Neither the Mail Service Prescription Drug Program nor the Specialty Drug Pharmacy Program will fill your prescription for a drug requiring prior approval until you have obtained prior approval. CVS Caremark, the program administrator, will hold your prescription for you up to 30 days. If prior approval is not obtained within 30 days, your prescription will be unable to be filled and a letter will be mailed to you explaining the prior approval procedures.
Note: Both Preferred and Non-preferred retail pharmacies may offer options for ordering prescription drugs online. Drugs ordered online may be delivered to your home; however, these online orders are not a part of the Mail Service Prescription Drug Program.
Note: Due to manufacturer restrictions, a small number of specialty drugs used to treat rare or uncommon conditions may be available only through a Preferred retail pharmacy.
• What is covered.
Under Basic Option, we use a managed formulary for certain drug classes. If you purchase a drug in a class included in the managed formulary that is not on the managed formulary, you will pay the full cost of that drug since that drug is not covered under your benefit.
Under Basic Option, we use a managed formulary for certain drug classes. If you purchase a drug in a class included in the managed formulary that is not on the managed formulary, you will pay the full cost of that drug since that drug is not covered under your benefit.