2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 112
Section 5(f). Prescription Drug Benefits
Page 112
Benefits Description
Covered Medications and Supplies (cont.)
Other Preferred Diabetic Medications, Test Strips, and Supplies
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 2 (preferred diabetic medications and supplies): 20% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 2 (preferred insulins): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply) (no deductible)
Non-preferred retail pharmacies: You pay all charges
Basic Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 2 (preferred brand-name drugs): $30 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program:
Note: See pages 115-116 for Tier 2, 3, 4, and 5 prescription drug benefits.
Benefits will be provided for syringes, pens and pen needles and test strips at Tier 2 (diabetic medications and supplies) for Standard Option members, and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. See pages 115-116 for more information.
Standard Option - You Pay
Tier 2 (preferred brand-name drug): $40 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 2 (preferred brand-name drugs) $50 copayment for each purchase of up to a 90-day supply
Covered Medications and Supplies (cont.)
Other Preferred Diabetic Medications, Test Strips, and Supplies
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 2 (preferred diabetic medications and supplies): 20% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 2 (preferred insulins): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply) (no deductible)
Non-preferred retail pharmacies: You pay all charges
Basic Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 2 (preferred brand-name drugs): $30 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program:
Note: See pages 115-116 for Tier 2, 3, 4, and 5 prescription drug benefits.
Benefits will be provided for syringes, pens and pen needles and test strips at Tier 2 (diabetic medications and supplies) for Standard Option members, and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. See pages 115-116 for more information.
Standard Option - You Pay
Tier 2 (preferred brand-name drug): $40 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 2 (preferred brand-name drugs) $50 copayment for each purchase of up to a 90-day supply
Benefits Description
Medications to promote better health as recommended under the Patient Protection and Affordable Care Act (the “Affordable Care Act”), limited to:
Note: Benefits are not available for acetaminophen, ibuprofen, naproxen, etc.
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
Medications to promote better health as recommended under the Patient Protection and Affordable Care Act (the “Affordable Care Act”), limited to:
- Iron supplements for children from age 6 months through 12 months
- Oral fluoride supplements for children from age 6 months through 5 years
- Folic acid supplements, 0.4 mg to 0.8 mg, for individuals capable of pregnancy
- Low-dose aspirin (81 mg per day) for pregnant members at risk for preeclampsia
- Aspirin for men age 45 through 79 and women age 50 through 79
- Generic cholesterol-lowering statin drugs
Note: Benefits are not available for acetaminophen, ibuprofen, naproxen, etc.
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