2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 117
Section 5(f). Prescription Drug Benefits
Page 117
Benefits Description
We cover the first prescription filled for certain bowel preparation medications for colorectal cancer screenings with no member cost-share. We also cover certain antiretroviral therapy medications for HIV for those at risk but who do not have HIV. You can view the list of covered medications on our website at www.fepblue.org or call 800-624-5060, TTY: 711, for assistance.
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
We cover the first prescription filled for certain bowel preparation medications for colorectal cancer screenings with no member cost-share. We also cover certain antiretroviral therapy medications for HIV for those at risk but who do not have HIV. You can view the list of covered medications on our website at www.fepblue.org or call 800-624-5060, TTY: 711, for assistance.
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
Benefits Description
Opioid Reversal Agents: Tier 1 medications limited to generic naloxone nasal spray and injectable
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year (no deductible)
Correction, 3/14/2024
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a combined 90-day supply through any of our pharmacy programsa 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Basic Option - You Pay
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year
Correction, 3/14/2024
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a combined 90-day supply through any of our pharmacy programsa 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Non-preferred Retail Pharmacies:
Standard Option - You Pay
You pay all charges
Basic Option - You Pay
You pay all charges
Mail Service Prescription Drug Program:
Standard Option - You Pay
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year (no deductible)
Correction, 3/14/2024
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a combined 90-day supply through any of our pharmacy programsa 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year
Correction, 3/14/2024
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a combined 90-day supply through any of our pharmacy programsa 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Opioid Reversal Agents: Tier 1 medications limited to generic naloxone nasal spray and injectable
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year (no deductible)
Correction, 3/14/2024
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a combined 90-day supply through any of our pharmacy programs
Basic Option - You Pay
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year
Correction, 3/14/2024
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a combined 90-day supply through any of our pharmacy programs
Non-preferred Retail Pharmacies:
Standard Option - You Pay
You pay all charges
Basic Option - You Pay
You pay all charges
Mail Service Prescription Drug Program:
Standard Option - You Pay
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year (no deductible)
Correction, 3/14/2024
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a combined 90-day supply through any of our pharmacy programs
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year
Correction, 3/14/2024
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a combined 90-day supply through any of our pharmacy programs
Benefits Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Remicade, Renflexis, and Inflectra are not covered for prescriptions obtained from a retail pharmacy, Mail Service Prescription or through the Specialty Drug Program
- Medical supplies such as dressings and antiseptics
- Drugs and supplies for cosmetic purposes
- Supplies for weight loss
- Drugs for orthodontic care, dental implants, and periodontal disease
Correction, 3/14/2024 - Drugs used in conjunction with non-covered assisted reproductive technology (ART) and assisted insemination procedures
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Covered Medications and Supplies - continued on next page