2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 115
Section 5(f). Prescription Drug Benefits
Page 115
Benefits Description
Covered Medications and Supplies (cont.)
Anti-hypertensive Medications
Preferred Retail Pharmacies:
Note: See Section 3 for information about drugs and supplies that require prior approval.
Standard Option - You Pay
Tier 1 (generic drug): $3 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
Correction, 3/14/2024
Mail Service Prescription Drug Program:
Note: You must obtain prior approval for certain drugs before Mail Service will fill your prescription.
Note: See earlier in this section for Tier 2, 3, 4, and 5 prescription drug benefits.
Standard Option - You Pay
Tier 1 (generic drug): $3 copayment (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Covered Medications and Supplies (cont.)
Anti-hypertensive Medications
Preferred Retail Pharmacies:
Note: See Section 3 for information about drugs and supplies that require prior approval.
Standard Option - You Pay
Tier 1 (generic drug): $3 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
Correction, 3/14/2024
Mail Service Prescription Drug Program:
Note: You must obtain prior approval for certain drugs before Mail Service will fill your prescription.
Note: See earlier in this section for Tier 2, 3, 4, and 5 prescription drug benefits.
Standard Option - You Pay
Tier 1 (generic drug): $3 copayment (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Benefits Description
Note: We provide benefits in full for OTC contraceptive drugs and devices when the contraceptives meet U.S. FDA standards for OTC products. To receive benefits, you must use a retail pharmacy and present the pharmacist with a written prescription from your physician.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
- Over-the-counter (OTC) contraceptive drugs and devices, limited to:
- Emergency contraceptive pills
- Condoms
- Spermicides
- Sponges
- Emergency contraceptive pills
Note: We provide benefits in full for OTC contraceptive drugs and devices when the contraceptives meet U.S. FDA standards for OTC products. To receive benefits, you must use a retail pharmacy and present the pharmacist with a written prescription from your physician.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
Benefits Description
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network (see below) and administered in compliance with applicable state law and pharmacy certification requirements.
Note: Our vaccine network is a network of Preferred retail pharmacies that have agreements with us to administer one or more routine immunizations. Check with your pharmacy or call our Retail Pharmacy Program at 800-624-5060, TTY: 711, to find out which vaccines your pharmacy can provide.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network (see below) and administered in compliance with applicable state law and pharmacy certification requirements.
Note: Our vaccine network is a network of Preferred retail pharmacies that have agreements with us to administer one or more routine immunizations. Check with your pharmacy or call our Retail Pharmacy Program at 800-624-5060, TTY: 711, to find out which vaccines your pharmacy can provide.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Benefits Description
Metformin and metformin extended release (excluding osmotic and modified release generic drugs)
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Mail Service Prescription Drug Program:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Metformin and metformin extended release (excluding osmotic and modified release generic drugs)
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Mail Service Prescription Drug Program:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Covered Medications and Supplies - continued on next page