2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 103
Section 5(f). Prescription Drug Benefits
Page 103
Here is how to obtain your prescription drugs and supplies:
Note: For prescription drugs billed by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown below for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy. See later in this section for benefit information about prescription drugs supplied by Non-preferred retail pharmacies.
- Make sure you have your Plan ID card when you are ready to purchase your prescription.
- Go to any Preferred retail pharmacy, or
- Visit the website of your retail pharmacy to request your prescriptions online and delivery, if available.
- For a listing of Preferred retail pharmacies, call the Retail Pharmacy Program at 800-624-5060, TTY: 711, or visit our website, www.fepblue.org.
Note: For prescription drugs billed by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown below for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy. See later in this section for benefit information about prescription drugs supplied by Non-preferred retail pharmacies.
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
Preferred Retail Pharmacies
Covered drugs and supplies, such as:
Standard Option - You Pay
Tier 1 (generic drug): $7.50 copayment for each purchase of up to a 30-day supply ($22.50 copayment for a 31 to 90-day supply) (no deductible)
Note: You pay a $5 copayment for each purchase of up to a 30-day supply ($15 copayment for a 31 to 90-day supply) when Medicare Part B is primary.
Note: You may be eligible to receive your first 4 generic prescriptions filled (and/or refills ordered) at no charge when you change from certain brand-name drugs to a corresponding generic drug replacement, as previously described.
Tier 2 (preferred brand-name drug): 30% 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): 30% of the Plan allowance (no deductible), limited to one purchase of up to a 30-day supply
Basic Option - You Pay
Tier 1 (generic drug): $15 copayment for each purchase of up to a 30-day supply ($40 copayment for a 31 to 90-day supply)
Tier 2 (preferred brand-name drug): $60 copayment for each purchase of up to a 30-day supply ($180 copayment for a 31 to 90-day supply)
Tier 3 (non-preferred brand-name drug): 60% of the Plan allowance ($90 minimum) for each purchase of up to a 30-day supply ($250 minimum for a 31 to 90-day supply)
Tier 4 (preferred specialty drug): $85 copayment limited to one purchase of up to a 30-day supply
Tier 5 (non-preferred specialty drug): $110 copayment limited to one purchase of up to a 30-day supply
When Medicare Part B is primary, you pay the following:
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)
Benefit Description
Covered Medication and Supplies
Preferred 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)
- Contraceptive drugs and devices, limited to:
- Diaphragms and contraceptive rings
- Injectable contraceptives
- Intrauterine devices (IUDs)
- Implantable contraceptives
- Oral and transdermal contraceptives
- Diaphragms and contraceptive rings
- Medical foods
- Insulin, diabetic test strips, lancets, and tubeless insulin delivery systems (See Section 5(a) for our coverage of insulin pumps with tubes.)
- Needles and disposable syringes for the administration of covered medications
Standard Option - You Pay
Tier 1 (generic drug): $7.50 copayment for each purchase of up to a 30-day supply ($22.50 copayment for a 31 to 90-day supply) (no deductible)
Note: You pay a $5 copayment for each purchase of up to a 30-day supply ($15 copayment for a 31 to 90-day supply) when Medicare Part B is primary.
Note: You may be eligible to receive your first 4 generic prescriptions filled (and/or refills ordered) at no charge when you change from certain brand-name drugs to a corresponding generic drug replacement, as previously described.
Tier 2 (preferred brand-name drug): 30% 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): 30% of the Plan allowance (no deductible), limited to one purchase of up to a 30-day supply
Basic Option - You Pay
Tier 1 (generic drug): $15 copayment for each purchase of up to a 30-day supply ($40 copayment for a 31 to 90-day supply)
Tier 2 (preferred brand-name drug): $60 copayment for each purchase of up to a 30-day supply ($180 copayment for a 31 to 90-day supply)
Tier 3 (non-preferred brand-name drug): 60% of the Plan allowance ($90 minimum) for each purchase of up to a 30-day supply ($250 minimum for a 31 to 90-day supply)
Tier 4 (preferred specialty drug): $85 copayment limited to one purchase of up to a 30-day supply
Tier 5 (non-preferred specialty drug): $110 copayment limited to one purchase of up to a 30-day supply
When Medicare Part B is primary, you pay the following:
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)
Covered Medication and Supplies - continued on next page