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
Retail Pharmacies
Covered drugs and supplies, such as:
Note: For a list of the Network Long-Term Care pharmacies, call 888-338-7737, TTY: 711.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 30-day supply ($15 copayment for a 31 to 90-day supply) (no deductible)
Tier 2 (preferred brand-name drug): 15% 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): $60 copayment for each purchase of up to a 30-day supply ($170 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
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)
Tier 2 (preferred brand-name drug): $45 copayment for each purchase of up to a 30-day supply ($135 copayment for a 31 to 90-day supply)
Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance ($60 minimum) for each purchase of up to a 30-day supply ($175 minimum for a 31 to 90-day supply)
Tier 4 (preferred specialty drug): $75 copayment for each purchase of up to a 30-day supply; ($195 for 31 to 90-day supply)
Benefits Description
Covered Medications and Supplies
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
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.
- 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
Tier 1 (generic drug): $5 copayment for each purchase of up to a 30-day supply ($15 copayment for a 31 to 90-day supply) (no deductible)
Tier 2 (preferred brand-name drug): 15% 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): $60 copayment for each purchase of up to a 30-day supply ($170 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
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)
Tier 2 (preferred brand-name drug): $45 copayment for each purchase of up to a 30-day supply ($135 copayment for a 31 to 90-day supply)
Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance ($60 minimum) for each purchase of up to a 30-day supply ($175 minimum for a 31 to 90-day supply)
Tier 4 (preferred specialty drug): $75 copayment for each purchase of up to a 30-day supply; ($195 for 31 to 90-day supply)