2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 119
Section 5(f). Prescription Drug Benefits
Page 119
Benefits Description
Covered Medications and Supplies (cont.)
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Covered Medications and Supplies (cont.)
- Drugs for which prior approval has been denied or not obtained
- Drugs and supplies related to sexual dysfunction or sexual inadequacy
- Drugs and covered-drug-related supplies for the treatment of gender dysphoria if not obtained from a retail pharmacy or through the Mail Service Prescription Drug Program or Specialty Drug Pharmacy Program as described on page 110110
- Drugs purchased through the mail or internet from pharmacies outside the United States by members located in the United States
- Over-the-counter (OTC) contraceptive drugs and devices, except as described on page 110
- Drugs used to terminate pregnancy
- Sublingual allergy desensitization drugs, except as described on page 51
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefits Description
Drugs From Other Sources
Covered prescription drugs and supplies not obtained at a retail pharmacy, through the Specialty Drug Pharmacy Program, or, for Standard Option members and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. This includes drugs and supplies covered only under the medical benefit.
Note: Prior approval is required for certain high-cost drugs obtained outside one of our pharmacy programs. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/highcostdrugs for a list of these drugs. See page 22 for more information on prior approval.
Note: We cover drugs and supplies purchased overseas as shown here, as long as they are the equivalent to drugs and supplies that by Federal law of the United States require a prescription. Please refer to page 131 in Section 5(i) for more information.
Note: For covered prescription drugs and supplies purchased outside of the United States, Puerto Rico, and the U.S. Virgin Islands, please submit claims on an Overseas Claim Form. See Section 5(i) for information on how to file claims for overseas services.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating professional provider: 35% of the Plan allowance (deductible applies)
Non-participating professional provider: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: 30% of the Plan allowance
Participating professional provider: You pay all charges
Non-participating professional provider: You pay all charges
Member or Non-member facilities: You pay all charges
Drugs From Other Sources
Covered prescription drugs and supplies not obtained at a retail pharmacy, through the Specialty Drug Pharmacy Program, or, for Standard Option members and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. This includes drugs and supplies covered only under the medical benefit.
Note: Prior approval is required for certain high-cost drugs obtained outside one of our pharmacy programs. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/highcostdrugs for a list of these drugs. See page 22 for more information on prior approval.
Note: We cover drugs and supplies purchased overseas as shown here, as long as they are the equivalent to drugs and supplies that by Federal law of the United States require a prescription. Please refer to page 131 in Section 5(i) for more information.
Note: For covered prescription drugs and supplies purchased outside of the United States, Puerto Rico, and the U.S. Virgin Islands, please submit claims on an Overseas Claim Form. See Section 5(i) for information on how to file claims for overseas services.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating professional provider: 35% of the Plan allowance (deductible applies)
Non-participating professional provider: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Member facilities: 35% of the Plan allowance (deductible applies)
Non-member facilities: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
Preferred: 30% of the Plan allowance
Participating professional provider: You pay all charges
Non-participating professional provider: You pay all charges
Member or Non-member facilities: You pay all charges
Drugs From Other Sources - continued on next page