2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 112
Section 5(f). Prescription Drug Benefits
Page 112
Benefit Description
Covered Medication and Supplies (cont.)
Note: For a list of the Network Long-Term Care pharmacies, call 888-338-7737, TTY: 711.
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
Tier 4 (preferred specialty drug): $75 copayment for each purchase of up to a 30-day supply; ($195 for 31 to 90-day supply)
Covered Medication and Supplies (cont.)
- Contraceptive drugs and devices, limited to:
- Diaphragms and contraceptive rings
- Injectable contraceptives
- Intrauterine devices (IUDs)
- Implantable contraceptives
- Oral and transdermal contraceptives
Note: We waive your cost-share for available forms of generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative when purchased from a network retail pharmacy.
- 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
- Clotting factors and anti-inhibitor complexes for the treatment of hemophilia
Note: For a list of the Network Long-Term Care pharmacies, call 888-338-7737, TTY: 711.
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
Tier 4 (preferred specialty drug): $75 copayment for each purchase of up to a 30-day supply; ($195 for 31 to 90-day supply)
Benefit Description
Mail Service Prescription Drug Program
For members enrolled in the FEP Medicare Prescription Drug Program, if your doctor orders more than a 21-day supply of covered drugs or supplies, up to a 90-day supply, you can use this service for your prescriptions and refills.
Please refer to Section 7 for instructions on how to use the Mail Service Prescription Drug Program.
Note: You must obtain prior approval for certain drugs before Mail Service will fill your prescription. See Section 3.
Note: Not all drugs are available through the Mail Service Prescription Drug Program.
Note: We waive your cost-share for available forms of generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative.
Contact Us: If you have any questions about this program, or need assistance with your Mail Service drug orders, please call 800-262-7890, TTY: 711.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $85 copayment (no deductible)
Tier 3 (non-preferred brands): $125 copayment (no deductible)
Tier 4 (specialty-drugs): $150 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $15 copayment
Tier 2 (preferred brand-name drug): $95 copayment
Tier 3 (non-preferred brands): $125 copayment
Tier 4 (specialty-drugs): $150 copayment
Mail Service Prescription Drug Program
For members enrolled in the FEP Medicare Prescription Drug Program, if your doctor orders more than a 21-day supply of covered drugs or supplies, up to a 90-day supply, you can use this service for your prescriptions and refills.
Please refer to Section 7 for instructions on how to use the Mail Service Prescription Drug Program.
Note: You must obtain prior approval for certain drugs before Mail Service will fill your prescription. See Section 3.
Note: Not all drugs are available through the Mail Service Prescription Drug Program.
Note: We waive your cost-share for available forms of generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative.
Contact Us: If you have any questions about this program, or need assistance with your Mail Service drug orders, please call 800-262-7890, TTY: 711.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $85 copayment (no deductible)
Tier 3 (non-preferred brands): $125 copayment (no deductible)
Tier 4 (specialty-drugs): $150 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $15 copayment
Tier 2 (preferred brand-name drug): $95 copayment
Tier 3 (non-preferred brands): $125 copayment
Tier 4 (specialty-drugs): $150 copayment