2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 113
Section 5(f). Prescription Drug Benefits
Page 113
Benefits Description
Covered Medications and Supplies (cont.)
Note: Benefits for the medications listed on the previous page are subject to the dispensing limitations described on page 106 and are limited to recommended prescribed limits.
Note: To receive benefits, you must use a Preferred retail pharmacy and present a written prescription from your physician to the pharmacist.
Note: A complete list of USPSTF-recommended preventive care services is available online at: www.healthcare.gov/preventive-care-benefits. See pages 42-46 in Section 5(a) for information about other covered preventive care services.
Note: See page 117 for our coverage of smoking and tobacco cessation medications.
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 (cont.)
Note: Benefits for the medications listed on the previous page are subject to the dispensing limitations described on page 106 and are limited to recommended prescribed limits.
Note: To receive benefits, you must use a Preferred retail pharmacy and present a written prescription from your physician to the pharmacist.
Note: A complete list of USPSTF-recommended preventive care services is available online at: www.healthcare.gov/preventive-care-benefits. See pages 42-46 in Section 5(a) for information about other covered preventive care services.
Note: See page 117 for our coverage of smoking and tobacco cessation medications.
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
Benefits Description
Generic medications to reduce breast cancer risk for women, age 35 or over, who have not been diagnosed with any form of breast cancer
Note: Your physician must send a completed Coverage Request Form to CVS Caremark before you fill the prescription. Call CVS Caremark at 800-624-5060, TTY: 711, to request this form. You can also obtain the Coverage Request Form through our website at www.fepblue.org.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Mail Service Prescription Drug Program: Nothing (no deductible)
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
Basic Option - When Medicare Part B is primary, you pay the following:
Mail Service Prescription Drug Program: Nothing
Generic medications to reduce breast cancer risk for women, age 35 or over, who have not been diagnosed with any form of breast cancer
Note: Your physician must send a completed Coverage Request Form to CVS Caremark before you fill the prescription. Call CVS Caremark at 800-624-5060, TTY: 711, to request this form. You can also obtain the Coverage Request Form through our website at www.fepblue.org.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Mail Service Prescription Drug Program: Nothing (no deductible)
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
Basic Option - When Medicare Part B is primary, you pay the following:
Mail Service Prescription Drug Program: Nothing
Benefits Description
We cover the first prescription filled for certain bowel preparation medications for colorectal cancer screenings with no member cost-share. We also cover certain antiretroviral therapy medications for HIV for those at risk but who do not have HIV. You can view the list of covered medications on our website at www.fepblue.org or call 800-624-5060, TTY: 711, for assistance.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Mail Service Prescription Drug Program: Nothing (no deductible)
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
Basic Option - When Medicare Part B is primary, you pay the following:
Mail Service Prescription Drug Program: Nothing
We cover the first prescription filled for certain bowel preparation medications for colorectal cancer screenings with no member cost-share. We also cover certain antiretroviral therapy medications for HIV for those at risk but who do not have HIV. You can view the list of covered medications on our website at www.fepblue.org or call 800-624-5060, TTY: 711, for assistance.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Mail Service Prescription Drug Program: Nothing (no deductible)
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
Basic Option - When Medicare Part B is primary, you pay the following:
Mail Service Prescription Drug Program: Nothing
Benefits Description
Opioid Reversal Agents: Tier 1 medications limited to generic naloxone nasal spray and injectable
Preferred Retail Pharmacies
Standard Option - You Pay
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year (no deductible)
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Basic Option - You Pay
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Non-preferred Retail Pharmacies
Standard Option - You Pay
You pay all charges
Basic Option - You Pay
You pay all charges
Opioid Reversal Agents: Tier 1 medications limited to generic naloxone nasal spray and injectable
Preferred Retail Pharmacies
Standard Option - You Pay
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year (no deductible)
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Basic Option - You Pay
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Non-preferred Retail Pharmacies
Standard Option - You Pay
You pay all charges
Basic Option - You Pay
You pay all charges
Covered Medications and Supplies - continued on next page