2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 108
Section 5(f). Prescription Drug Benefits
Page 108
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.
Benefits Description
Covered Medications and Supplies
Asthma Medications
Preferred Retail Pharmacies:
Note: See page 24 for information about drugs and supplies that require prior approval.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): 20% of the Plan allowance (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
Tier 2 (preferred brand-name drug): $35 copayment for each purchase of up to a 30-day supply ($105 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $30 copayment for each purchase of up to a 30-day supply ($90 copayment for a 31 to 90-day supply)
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: See pages 114-116 for Tier 3, 4 and 5 prescription drug benefits.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $65 copayment (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $75 copayment
Benefits Description
Covered Medications and Supplies
Asthma Medications
Preferred Retail Pharmacies:
Note: See page 24 for information about drugs and supplies that require prior approval.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): 20% of the Plan allowance (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
Tier 2 (preferred brand-name drug): $35 copayment for each purchase of up to a 30-day supply ($105 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $30 copayment for each purchase of up to a 30-day supply ($90 copayment for a 31 to 90-day supply)
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: See pages 114-116 for Tier 3, 4 and 5 prescription drug benefits.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $65 copayment (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $75 copayment
Benefits Description
Anti-hypertensive Medications
Preferred Retail Pharmacies:
Note: See page 24 for information about drugs and supplies that require prior approval.
Standard Option - You Pay
Tier 1 (generic drug): $3 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
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: See pages 114-116 for Tier 2, 3, 4, and 5 prescription drug benefits.
Standard Option - You Pay
Tier 1 (generic drug): $3 copayment (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Anti-hypertensive Medications
Preferred Retail Pharmacies:
Note: See page 24 for information about drugs and supplies that require prior approval.
Standard Option - You Pay
Tier 1 (generic drug): $3 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
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: See pages 114-116 for Tier 2, 3, 4, and 5 prescription drug benefits.
Standard Option - You Pay
Tier 1 (generic drug): $3 copayment (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Covered Medications and Supplies - continued on next page