2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(f). Prescription Drug Benefits
Covered Medications and Supplies
Section 5. Benefits
Section 5(f). Prescription Drug Benefits
Covered Medications and Supplies
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
Mail Service Prescription Drug Program
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 - When Medicare Part B is primary, you pay the following:
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.
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
Mail Service Prescription Drug Program
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 - When Medicare Part B is primary, you pay the following:
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.