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
Here is how to obtain your prescription drugs and supplies:
Preferred Retail Pharmacies
Note: Benefits for Tier 4 and Tier 5 specialty drugs purchased at a Preferred pharmacy are limited to one purchase of up to a 30-day supply for each prescription dispensed. All refills must be obtained through the Specialty Drug Pharmacy Program. See page 116 for more information.
Note: For prescription drugs billed for by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on this page for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy. For benefit information about prescription drugs supplied by Non-preferred retail pharmacies, please refer to page 115.
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
Tier 1 (generic drug): $7.50 copayment for each purchase of up to a 30-day supply ($22.50 copayment for a 31 to 90-day supply) (no deductible)
Note: You pay a $5 copayment for each purchase of up to a 30-day supply ($15 copayment for a 31 to 90-day supply) 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): 30% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 4 (preferred specialty drug): 30% of the Plan allowance (no deductible), limited to one purchase of up to a 30-day supply
Tier 5 (non-preferred specialty drug): 30% of the Plan allowance (no deductible), limited to one purchase of up to a 30-day supply
Basic Option - You Pay
Tier 1 (generic drug): $15 copayment for each purchase of up to a 30-day supply ($40 copayment for a 31 to 90-day supply)
Tier 2 (preferred brand-name drug): $60 copayment for each purchase of up to a 30-day supply ($180 copayment for a 31 to 90-day supply)
Tier 3 (non-preferred brand-name drug): 60% of the Plan allowance ($90 minimum) for each purchase of up to a 30-day supply ($250 minimum for a 31 to 90-day supply)
Tier 4 (preferred specialty drug): $85 copayment limited to one purchase of up to a 30-day supply
Tier 5 (non-preferred specialty drug): $110 copayment limited to one purchase of up to a 30-day supply
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $10 copayment for each purchase of up to a 30-day supply ($30 copayment for a 31 to 90-day supply)
Tier 2 (preferred brand-name drug): $50 copayment for each purchase of up to a 30-day supply ($150 copayment for a 31 to 90-day supply)
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
Here is how to obtain your prescription drugs and supplies:
Preferred Retail Pharmacies
- Make sure you have your Plan ID card when you are ready to purchase your prescription.
- Go to any Preferred retail pharmacy, or
- Visit the website of your retail pharmacy to request your prescriptions online and delivery, if available.
- For a listing of Preferred retail pharmacies, call the Retail Pharmacy Program at 800-624-5060, TTY: 711, or visit our website, www.fepblue.org.
Note: Retail pharmacies that are Preferred for prescription drugs are not necessarily Preferred for durable medical equipment (DME) and medical supplies. To receive Preferred benefits for DME and covered medical supplies, you must use a Preferred DME or medical supply provider. See Section 5(a) for the benefit levels that apply to DME and medical supplies.
Note: Benefits for Tier 4 and Tier 5 specialty drugs purchased at a Preferred pharmacy are limited to one purchase of up to a 30-day supply for each prescription dispensed. All refills must be obtained through the Specialty Drug Pharmacy Program. See page 116 for more information.
Note: For prescription drugs billed for by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on this page for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy. For benefit information about prescription drugs supplied by Non-preferred retail pharmacies, please refer to page 115.
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
Tier 1 (generic drug): $7.50 copayment for each purchase of up to a 30-day supply ($22.50 copayment for a 31 to 90-day supply) (no deductible)
Note: You pay a $5 copayment for each purchase of up to a 30-day supply ($15 copayment for a 31 to 90-day supply) 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): 30% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 4 (preferred specialty drug): 30% of the Plan allowance (no deductible), limited to one purchase of up to a 30-day supply
Tier 5 (non-preferred specialty drug): 30% of the Plan allowance (no deductible), limited to one purchase of up to a 30-day supply
Basic Option - You Pay
Tier 1 (generic drug): $15 copayment for each purchase of up to a 30-day supply ($40 copayment for a 31 to 90-day supply)
Tier 2 (preferred brand-name drug): $60 copayment for each purchase of up to a 30-day supply ($180 copayment for a 31 to 90-day supply)
Tier 3 (non-preferred brand-name drug): 60% of the Plan allowance ($90 minimum) for each purchase of up to a 30-day supply ($250 minimum for a 31 to 90-day supply)
Tier 4 (preferred specialty drug): $85 copayment limited to one purchase of up to a 30-day supply
Tier 5 (non-preferred specialty drug): $110 copayment limited to one purchase of up to a 30-day supply
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $10 copayment for each purchase of up to a 30-day supply ($30 copayment for a 31 to 90-day supply)
Tier 2 (preferred brand-name drug): $50 copayment for each purchase of up to a 30-day supply ($150 copayment for a 31 to 90-day supply)
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.
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.
Contact Us: If you have any questions about this program, or need assistance with your Mail Service drug orders, please call 800-262-7890, TTY: 711.
Note: If the cost of your prescription is less than your copayment, you pay only the cost of your prescription. The Mail Service Prescription Drug Program will charge you the lesser of the prescription cost or the copayment when you place your order. If you have already sent in your copayment, they will credit your account with any difference.
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.
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.
Contact Us: If you have any questions about this program, or need assistance with your Mail Service drug orders, please call 800-262-7890, TTY: 711.
Note: If the cost of your prescription is less than your copayment, you pay only the cost of your prescription. The Mail Service Prescription Drug Program will charge you the lesser of the prescription cost or the copayment when you place your order. If you have already sent in your copayment, they will credit your account with any difference.
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.
Benefits Description
Specialty Drug Pharmacy Program
We cover specialty drugs that are listed on the Service Benefit Plan Specialty Drug List. This list is subject to change. For the most up-to-date list, call the phone number below or visit our website, www.fepblue.org. (See page 159 for the definition of “specialty drugs.”)
Each time you order a new specialty drug or refill, a Specialty Drug pharmacy representative will work with you to arrange a delivery time and location that are most convenient for you, as well as ask you about any side effects you may be experiencing. See page 138 for more details about the Program.
Note: Benefits for the first three fills of each Tier 4 or Tier 5 specialty drug are limited to a 30-day supply. Benefits are available for a 31 to 90-day supply after the third fill.
Note: Due to manufacturer restrictions, a small number of specialty drugs may only be available through a Preferred retail pharmacy. You will be responsible for paying only the copayments shown here for specialty drugs affected by these restrictions.
Contact Us: If you have any questions about this program, or need assistance with your specialty drug orders, please call 888-346-3731, TTY: 711.
Standard Option - You Pay
Tier 4 (preferred specialty drug): $65 copayment for each purchase of up to a 30-day supply ($185 copayment for a 31 to 90-day supply) (no deductible)
Tier 5 (non-preferred specialty drug): $85 copayment for each purchase of up to a 30-day supply ($240 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 4 (preferred specialty drug): $85 copayment for each purchase of up to a 30-day supply ($235 copayment for a 31 to 90-day supply)
Tier 5 (non-preferred specialty drug): $110 copayment for each purchase of up to a 30-day supply ($300 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 4 (preferred specialty drug): $80 copayment for each purchase of up to a 30-day supply ($210 copayment for a 31 to 90-day supply)
Tier 5 (non-preferred specialty drug): $100 copayment for each purchase of up to a 30-day supply ($255 copayment for a 31 to 90-day supply)
Specialty Drug Pharmacy Program
We cover specialty drugs that are listed on the Service Benefit Plan Specialty Drug List. This list is subject to change. For the most up-to-date list, call the phone number below or visit our website, www.fepblue.org. (See page 159 for the definition of “specialty drugs.”)
Each time you order a new specialty drug or refill, a Specialty Drug pharmacy representative will work with you to arrange a delivery time and location that are most convenient for you, as well as ask you about any side effects you may be experiencing. See page 138 for more details about the Program.
Note: Benefits for the first three fills of each Tier 4 or Tier 5 specialty drug are limited to a 30-day supply. Benefits are available for a 31 to 90-day supply after the third fill.
Note: Due to manufacturer restrictions, a small number of specialty drugs may only be available through a Preferred retail pharmacy. You will be responsible for paying only the copayments shown here for specialty drugs affected by these restrictions.
Contact Us: If you have any questions about this program, or need assistance with your specialty drug orders, please call 888-346-3731, TTY: 711.
Standard Option - You Pay
Tier 4 (preferred specialty drug): $65 copayment for each purchase of up to a 30-day supply ($185 copayment for a 31 to 90-day supply) (no deductible)
Tier 5 (non-preferred specialty drug): $85 copayment for each purchase of up to a 30-day supply ($240 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 4 (preferred specialty drug): $85 copayment for each purchase of up to a 30-day supply ($235 copayment for a 31 to 90-day supply)
Tier 5 (non-preferred specialty drug): $110 copayment for each purchase of up to a 30-day supply ($300 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 4 (preferred specialty drug): $80 copayment for each purchase of up to a 30-day supply ($210 copayment for a 31 to 90-day supply)
Tier 5 (non-preferred specialty drug): $100 copayment for each purchase of up to a 30-day supply ($255 copayment for a 31 to 90-day supply)