2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 111
Section 5(f). Prescription Drug Benefits
Page 111
Benefits Description
Covered Medications and Supplies (cont.)
Note: We provide benefits in full for OTC contraceptive drugs and devices when the contraceptives meet U.S. FDA standards for OTC products. To receive benefits, you must use a retail pharmacy and present the pharmacist with a written prescription from your physician.
Standard Option - You Pay
See previous page
Basic Option - You Pay
See previous page
Covered Medications and Supplies (cont.)
Note: We provide benefits in full for OTC contraceptive drugs and devices when the contraceptives meet U.S. FDA standards for OTC products. To receive benefits, you must use a retail pharmacy and present the pharmacist with a written prescription from your physician.
Standard Option - You Pay
See previous page
Basic Option - You Pay
See previous page
Benefits Description
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network (see below) and administered in compliance with applicable state law and pharmacy certification requirements. See pages 43 and 45 for specific coverage.
Note: Our vaccine network is a network of Preferred retail pharmacies that have agreements with us to administer one or more routine immunizations. Check with your pharmacy or call our Retail Pharmacy Program at 800-624-5060, TTY: 711, to find out which vaccines your pharmacy can provide.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network (see below) and administered in compliance with applicable state law and pharmacy certification requirements. See pages 43 and 45 for specific coverage.
Note: Our vaccine network is a network of Preferred retail pharmacies that have agreements with us to administer one or more routine immunizations. Check with your pharmacy or call our Retail Pharmacy Program at 800-624-5060, TTY: 711, to find out which vaccines your pharmacy can provide.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Benefits Description
Diabetic Meter Program
Members with diabetes may obtain one glucose meter kit every 365 days at no cost through our Diabetic Meter Program. To use this program, you must call the phone number listed below and request one of the eligible types of meters. The types of glucose meter kits available through the program are subject to change.
To order your free glucose meter kit, call us toll-free at 855-582-2024, Monday through Friday, from 9 a.m. to 7 p.m., Eastern Time, or visit our website at www.fepblue.org. The selected meter kit will be sent to you within 7 to 10 days of your request.
Note: Contact your physician to obtain a new prescription for the test strips and lancets to use with the new meter. See page 112 for more information.
Standard Option - You Pay
Nothing for a glucose meter kit ordered through the Diabetic Meter Program
Basic Option - You Pay
Nothing for a glucose meter kit ordered through the Diabetic Meter Program
Diabetic Meter Program
Members with diabetes may obtain one glucose meter kit every 365 days at no cost through our Diabetic Meter Program. To use this program, you must call the phone number listed below and request one of the eligible types of meters. The types of glucose meter kits available through the program are subject to change.
To order your free glucose meter kit, call us toll-free at 855-582-2024, Monday through Friday, from 9 a.m. to 7 p.m., Eastern Time, or visit our website at www.fepblue.org. The selected meter kit will be sent to you within 7 to 10 days of your request.
Note: Contact your physician to obtain a new prescription for the test strips and lancets to use with the new meter. See page 112 for more information.
Standard Option - You Pay
Nothing for a glucose meter kit ordered through the Diabetic Meter Program
Basic Option - You Pay
Nothing for a glucose meter kit ordered through the Diabetic Meter Program
Benefits Description
Metformin and metformin extended release (excluding osmotic and modified release generic drugs)
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Mail Service Prescription Drug Program:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Metformin and metformin extended release (excluding osmotic and modified release generic drugs)
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Mail Service Prescription Drug Program:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Covered Medications and Supplies - continued on next page