2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 115
Section 5(f). Prescription Drug Benefits
Page 115
Benefits Description
Covered Medications and Supplies (cont.)
Note: For a list of the Preferred Network Long Term Care pharmacies, call 800-624-5060, TTY: 711.
Note: For coordination of benefits purposes, if you need a statement of Preferred retail pharmacy benefits in order to file claims with your other coverage when this Plan is the primary payor, call the Retail Pharmacy Program at 800-624-5060, TTY: 711, or visit our website at www.fepblue.org.
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.
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance ($60 minimum) for each purchase of up to a 30-day supply ($175 minimum for a 31 to 90-day supply)
Tier 4 (preferred specialty drug): $80 copayment limited to one purchase of up to a 30-day supply
Tier 5 (non-preferred specialty drug): $100 copayment limited to one purchase of up to a 30-day supply
Covered Medications and Supplies (cont.)
Note: For a list of the Preferred Network Long Term Care pharmacies, call 800-624-5060, TTY: 711.
Note: For coordination of benefits purposes, if you need a statement of Preferred retail pharmacy benefits in order to file claims with your other coverage when this Plan is the primary payor, call the Retail Pharmacy Program at 800-624-5060, TTY: 711, or visit our website at www.fepblue.org.
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.
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance ($60 minimum) for each purchase of up to a 30-day supply ($175 minimum for a 31 to 90-day supply)
Tier 4 (preferred specialty drug): $80 copayment limited to one purchase of up to a 30-day supply
Tier 5 (non-preferred specialty drug): $100 copayment limited to one purchase of up to a 30-day supply
Benefits Description
Non-preferred Retail Pharmacies
Standard Option - You Pay
45% of the Plan allowance (Average wholesale price – AWP), plus any difference between our allowance and the billed amount (no deductible)
Note: If you use a Non-preferred retail pharmacy, you must pay the full cost of the drug or supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed. Please refer to Section 7 for instructions on how to file prescription drug claims.
Basic Option - You Pay
All charges
Non-preferred Retail Pharmacies
Standard Option - You Pay
45% of the Plan allowance (Average wholesale price – AWP), plus any difference between our allowance and the billed amount (no deductible)
Note: If you use a Non-preferred retail pharmacy, you must pay the full cost of the drug or supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed. Please refer to Section 7 for instructions on how to file prescription drug claims.
Basic Option - You Pay
All charges
Benefits Description
Mail Service Prescription Drug Program
For Standard Option and Basic Option members when Medicare Part B is Primary, if your doctor orders more than a 21-day supply of covered drugs or supplies, up to a 90-day supply, you can use this service for your prescriptions and refills.
Please refer to Section 7 for instructions on how to use the Mail Service Prescription Drug Program.
Note: See page 24 for information about drugs and supplies that require prior approval. You must obtain prior approval before Mail Service will fill your prescription. See pages 24 and 107.
Note: Not all drugs are available through the Mail Service Prescription Drug Program. There are no specialty drugs available through the Mail Service Program.
Note: Please refer to page 116 for information about the Specialty Drug Pharmacy Program.
Standard Option - You Pay
Tier 1 (generic drug): $15 copayment (no deductible)
Note: You pay a $10 copayment per generic prescription filled (and/or refill ordered) when Medicare Part B is primary.
Note: You may be eligible to receive your first 4 generic prescriptions filled (and/or refills ordered) at no charge when you change from certain brand-name drugs to a corresponding generic drug replacement. See page 107 for information.
Tier 2 (preferred brand-name drug): $90 copayment (no deductible)
Tier 3 (non-preferred brand-name drug): $125 copayment (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $20 copayment
Tier 2 (preferred brand-name drug): $100 copayment
Tier 3 (non-preferred brand-name drug): $125 copayment
Basic Option - When Medicare Part B is not primary: No benefits
Note: Although you do not have access to the Mail Service Prescription Drug Program, you may request home delivery of prescription drugs you purchase from Preferred retail pharmacies offering options for online ordering. See page 108 of this Section for our payment levels for drugs obtained through Preferred retail pharmacies.
Mail Service Prescription Drug Program
For Standard Option and Basic Option members when Medicare Part B is Primary, if your doctor orders more than a 21-day supply of covered drugs or supplies, up to a 90-day supply, you can use this service for your prescriptions and refills.
Please refer to Section 7 for instructions on how to use the Mail Service Prescription Drug Program.
Note: See page 24 for information about drugs and supplies that require prior approval. You must obtain prior approval before Mail Service will fill your prescription. See pages 24 and 107.
Note: Not all drugs are available through the Mail Service Prescription Drug Program. There are no specialty drugs available through the Mail Service Program.
Note: Please refer to page 116 for information about the Specialty Drug Pharmacy Program.
Standard Option - You Pay
Tier 1 (generic drug): $15 copayment (no deductible)
Note: You pay a $10 copayment per generic prescription filled (and/or refill ordered) when Medicare Part B is primary.
Note: You may be eligible to receive your first 4 generic prescriptions filled (and/or refills ordered) at no charge when you change from certain brand-name drugs to a corresponding generic drug replacement. See page 107 for information.
Tier 2 (preferred brand-name drug): $90 copayment (no deductible)
Tier 3 (non-preferred brand-name drug): $125 copayment (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $20 copayment
Tier 2 (preferred brand-name drug): $100 copayment
Tier 3 (non-preferred brand-name drug): $125 copayment
Basic Option - When Medicare Part B is not primary: No benefits
Note: Although you do not have access to the Mail Service Prescription Drug Program, you may request home delivery of prescription drugs you purchase from Preferred retail pharmacies offering options for online ordering. See page 108 of this Section for our payment levels for drugs obtained through Preferred retail pharmacies.
Covered Medications and Supplies - continued on next page