2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 116
Section 5(f). Prescription Drug Benefits
Page 116
Benefits Description
Covered Medications and Supplies (cont.)
Note: We waive your cost-share for available forms of generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative.
Contact Us: If you have any questions about this program, or need assistance with your Mail Service drug orders, please call 800-262-7890, TTY: 711.
Note: If the cost of your prescription is less than your copayment, you pay only the cost of your prescription. The Mail Service Prescription Drug Program will charge you the lesser of the prescription cost or the copayment when you place your order. If you have already sent in your copayment, they will credit your account with any difference.
Standard Option - You Pay
See previous page
Basic Option - When Medicare Part B is primary, you pay the following:
See previous page
Covered Medications and Supplies (cont.)
Note: We waive your cost-share for available forms of generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative.
Contact Us: If you have any questions about this program, or need assistance with your Mail Service drug orders, please call 800-262-7890, TTY: 711.
Note: If the cost of your prescription is less than your copayment, you pay only the cost of your prescription. The Mail Service Prescription Drug Program will charge you the lesser of the prescription cost or the copayment when you place your order. If you have already sent in your copayment, they will credit your account with any difference.
Standard Option - You Pay
See previous page
Basic Option - When Medicare Part B is primary, you pay the following:
See previous page
Benefits Description
Specialty Drug Pharmacy Program
We cover specialty drugs that are listed on the Service Benefit Plan Specialty Drug List. This list is subject to change. For the most up-to-date list, call the phone number below or visit our website, www.fepblue.org. (See page 159 for the definition of “specialty drugs.”)
Each time you order a new specialty drug or refill, a Specialty Drug pharmacy representative will work with you to arrange a delivery time and location that are most convenient for you, as well as ask you about any side effects you may be experiencing. See page 138 for more details about the Program.
Note: Benefits for the first three fills of each Tier 4 or Tier 5 specialty drug are limited to a 30-day supply. Benefits are available for a 31 to 90-day supply after the third fill.
Note: Due to manufacturer restrictions, a small number of specialty drugs may only be available through a Preferred retail pharmacy. You will be responsible for paying only the copayments shown here for specialty drugs affected by these restrictions.
Contact Us: If you have any questions about this program, or need assistance with your specialty drug orders, please call 888-346-3731, TTY: 711.
Standard Option - You Pay
Tier 4 (preferred specialty drug): $65 copayment for each purchase of up to a 30-day supply ($185 copayment for a 31 to 90-day supply) (no deductible)
Tier 5 (non-preferred specialty drug): $85 copayment for each purchase of up to a 30-day supply ($240 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 4 (preferred specialty drug): $85 copayment for each purchase of up to a 30-day supply ($235 copayment for a 31 to 90-day supply)
Tier 5 (non-preferred specialty drug): $110 copayment for each purchase of up to a 30-day supply ($300 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 4 (preferred specialty drug): $80 copayment for each purchase of up to a 30-day supply ($210 copayment for a 31 to 90-day supply)
Tier 5 (non-preferred specialty drug): $100 copayment for each purchase of up to a 30-day supply ($255 copayment for a 31 to 90-day supply)
Specialty Drug Pharmacy Program
We cover specialty drugs that are listed on the Service Benefit Plan Specialty Drug List. This list is subject to change. For the most up-to-date list, call the phone number below or visit our website, www.fepblue.org. (See page 159 for the definition of “specialty drugs.”)
Each time you order a new specialty drug or refill, a Specialty Drug pharmacy representative will work with you to arrange a delivery time and location that are most convenient for you, as well as ask you about any side effects you may be experiencing. See page 138 for more details about the Program.
Note: Benefits for the first three fills of each Tier 4 or Tier 5 specialty drug are limited to a 30-day supply. Benefits are available for a 31 to 90-day supply after the third fill.
Note: Due to manufacturer restrictions, a small number of specialty drugs may only be available through a Preferred retail pharmacy. You will be responsible for paying only the copayments shown here for specialty drugs affected by these restrictions.
Contact Us: If you have any questions about this program, or need assistance with your specialty drug orders, please call 888-346-3731, TTY: 711.
Standard Option - You Pay
Tier 4 (preferred specialty drug): $65 copayment for each purchase of up to a 30-day supply ($185 copayment for a 31 to 90-day supply) (no deductible)
Tier 5 (non-preferred specialty drug): $85 copayment for each purchase of up to a 30-day supply ($240 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 4 (preferred specialty drug): $85 copayment for each purchase of up to a 30-day supply ($235 copayment for a 31 to 90-day supply)
Tier 5 (non-preferred specialty drug): $110 copayment for each purchase of up to a 30-day supply ($300 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 4 (preferred specialty drug): $80 copayment for each purchase of up to a 30-day supply ($210 copayment for a 31 to 90-day supply)
Tier 5 (non-preferred specialty drug): $100 copayment for each purchase of up to a 30-day supply ($255 copayment for a 31 to 90-day supply)
Covered Medications and Supplies - continued on next page