2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 120
Section 5(f). Prescription Drug Benefits
Page 120
Benefits Description
Drugs From Other Sources (cont.)
Standard Option - You Pay
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Basic Option - You Pay
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Drugs From Other Sources (cont.)
- Please refer to the Sections indicated for additional benefit information related to drugs obtained from other sources:
- Physician’s office – Section 5(a)
- Facility (inpatient or outpatient) – Section 5(c)
- Hospice agency – Section 5(c)
- Physician’s office – Section 5(a)
- Please refer to page 114 for prescription drugs obtained from a Preferred retail pharmacy, that are billed for by a skilled nursing facility, nursing home, or extended care facility.
Standard Option - You Pay
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Basic Option - You Pay
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Benefits Description
- Auto-immune infusion medications: Remicade, Renflexis and Inflectra
Note: Benefits for certain auto-immune infusion medications (limited to Remicade, Renflexis and Inflectra) are covered only when they are obtained by a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center).
Standard Option - You Pay
Preferred: 10% of the Plan allowance (deductible applies)
Participating professional provider: 15% of the Plan allowance (deductible applies)
Non-participating professional provider: 15% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Member facilities: 15% of the Plan allowance (deductible applies)
Non-member facilities: 15% of the Plan allowance (deductible applies), plus any difference between our allowance and billed amount.
Basic Option - You Pay
Preferred: 15% 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