2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 110
Section 5(f). Prescription Drug Benefits
Page 110
Benefits Description
Covered Medications and Supplies (cont.)
Covered Medications and Supplies (cont.)
- Insulin, diabetic test strips, lancets, and tubeless insulin delivery systems
Note: See page 58 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
Benefits Description
Note: We waive your cost-share for generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative, when you purchase them at a Preferred retail pharmacy or, for Standard Option members and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. See pages 115 and 116 for details.
Standard Option - You Pay
See below and pages 111-117
Basic Option - You Pay
See below and pages 111-117
- Drugs to aid smoking and tobacco cessation that require a prescription by Federal law
Note: We provide benefits for over-the-counter (OTC) smoking and tobacco cessation medications only as described on page 117.
Note: You may be eligible to receive smoking and tobacco cessation medications at no charge. See page 117 for more information.
- Drugs for the diagnosis and treatment of infertility, except as described on pages 118-119
- 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
- Diaphragms and contraceptive rings
Note: We waive your cost-share for generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative, when you purchase them at a Preferred retail pharmacy or, for Standard Option members and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. See pages 115 and 116 for details.
Standard Option - You Pay
See below and pages 111-117
Basic Option - You Pay
See below and pages 111-117
Benefits Description
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
- Over-the-counter (OTC) contraceptive drugs and devices, limited to:
- Emergency contraceptive pills
- Condoms
- Spermicides
- Sponges
- Emergency contraceptive pills
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
Covered Medications and Supplies - continued on next page