2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 116
Section 5(f). Prescription Drug Benefits
Page 116
Benefits Description
Medications to promote better health as recommended under the Patient Protection and Affordable Care Act (the “Affordable Care Act”), limited to:
Note: Benefits are not available for acetaminophen, ibuprofen, naproxen, etc.
Note: Benefits for these medications are subject to the dispensing limitations described earlier and are limited to recommended prescribed limits.
Note: To receive benefits, you must use a Preferred retail pharmacy and present a written prescription from your physician to the pharmacist.
Note: A complete list of USPSTF-recommended preventive care services is available online at: www.healthcare.gov/preventive-care-benefits. See Section 5(a) for information about other covered preventive care services.
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
Medications to promote better health as recommended under the Patient Protection and Affordable Care Act (the “Affordable Care Act”), limited to:
- Iron supplements for children from age 6 months through 12 months
- Oral fluoride supplements for children from age 6 months through 5 years
- Folic acid supplements, 0.4 mg to 0.8 mg, for individuals capable of pregnancy
- Low-dose aspirin (81 mg per day) for pregnant members at risk for preeclampsia
- Aspirin for men age 45 through 79 and women age 50 through 79
- Generic cholesterol-lowering statin drugs
Note: Benefits are not available for acetaminophen, ibuprofen, naproxen, etc.
Note: Benefits for these medications are subject to the dispensing limitations described earlier and are limited to recommended prescribed limits.
Note: To receive benefits, you must use a Preferred retail pharmacy and present a written prescription from your physician to the pharmacist.
Note: A complete list of USPSTF-recommended preventive care services is available online at: www.healthcare.gov/preventive-care-benefits. See Section 5(a) for information about other covered preventive care services.
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
Generic medications to reduce breast cancer risk for women, age 35 or over, who have not been diagnosed with any form of breast cancer
Note: Your physician must send a completed Coverage Request Form to CVS Caremark before you fill the prescription. Call CVS Caremark at 800-624-5060, TTY: 711, to request this form. You can also obtain the Coverage Request Form through our website at www.fepblue.org. This is not required if you are covered under the FEP Medicare Prescription Drug Program.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Mail Service Prescription Drug Program: Nothing (no deductible)
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
Basic Option - When Medicare Part B is primary, you pay the following:
Mail Service Prescription Drug Program: Nothing
Generic medications to reduce breast cancer risk for women, age 35 or over, who have not been diagnosed with any form of breast cancer
Note: Your physician must send a completed Coverage Request Form to CVS Caremark before you fill the prescription. Call CVS Caremark at 800-624-5060, TTY: 711, to request this form. You can also obtain the Coverage Request Form through our website at www.fepblue.org. This is not required if you are covered under the FEP Medicare Prescription Drug Program.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Mail Service Prescription Drug Program: Nothing (no deductible)
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
Basic Option - When Medicare Part B is primary, you pay the following:
Mail Service Prescription Drug Program: Nothing
Covered Medications and Supplies - continued on next page