2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(f). Prescription Drug Benefits
Covered Medications and Supplies
Section 5. Benefits
Section 5(f). Prescription Drug Benefits
Covered Medications and Supplies
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.
Benefits Description
Covered Medications and Supplies
Other Preferred Diabetic Medications, Test Strips, and Supplies
Network Retail Pharmacies:
Standard Option - You Pay
Tier 2 (preferred diabetic medications and supplies): 10% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 2 (preferred insulins): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $30 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program:
Note: See earlier in this section for Tier 2, 3, and 4 prescription drug benefits. Benefits will be provided for syringes, pens and pen needles and test strips at Tier 2 (diabetic medications and supplies) for those enrolled in the FEP Medicare Prescription Drug Program when obtained through the Mail Service Prescription Drug Program.
Standard Option - You Pay
Tier 2 (preferred brand-name drug): $40 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - You Pay
Tier 2 (preferred brand-name drugs): $50 copayment for each purchase of up to a 90-day supply
Benefits Description
Covered Medications and Supplies
Other Preferred Diabetic Medications, Test Strips, and Supplies
Network Retail Pharmacies:
Standard Option - You Pay
Tier 2 (preferred diabetic medications and supplies): 10% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 2 (preferred insulins): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $30 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program:
Note: See earlier in this section for Tier 2, 3, and 4 prescription drug benefits. Benefits will be provided for syringes, pens and pen needles and test strips at Tier 2 (diabetic medications and supplies) for those enrolled in the FEP Medicare Prescription Drug Program when obtained through the Mail Service Prescription Drug Program.
Standard Option - You Pay
Tier 2 (preferred brand-name drug): $40 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - You Pay
Tier 2 (preferred brand-name drugs): $50 copayment for each purchase of up to a 90-day supply
The pharmacy benefits starting here to the end of the section apply to all covered members, unless otherwise noted.