2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 106
Section 5(f). Prescription Drug Benefits
Page 106
• These are the dispensing limitations.
Standard Option: Subject to manufacturer packaging and your prescriber’s instructions, you may purchase up to a 90-day supply of covered drugs and supplies through the Retail Pharmacy Program. You may purchase a supply of more than 21 days up to 90 days through the Mail Service Prescription Drug Program for a single copayment.
Basic Option: When you fill Tier 1 (generic), Tier 2 (preferred brand-name), and Tier 3 (non-preferred brand-name) prescriptions at a Preferred retail pharmacy, you may purchase up to a 30-day supply for a single copayment, or up to a 90-day supply for additional copayments unless otherwise noted. Members with primary Medicare Part B coverage may purchase a supply of more than 21 days up to 90 days through the Mail Service Prescription Drug Program for a single copayment.
Under Standard Option and Basic Option
Benefits for Tier 4 and Tier 5 specialty drugs purchased at a retail 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. 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 90-day supply after the third fill of the specialty drug. See page 116 for more information.
Note: Certain drugs such as narcotics may have additional limits or requirements as established by the U.S. FDA or by national scientific or medical practice guidelines (such as Centers for Disease Control and Prevention, American Medical Association, etc.) on the quantities that a pharmacy may dispense. In addition, pharmacy dispensing practices are regulated by the state where they are located and may also be determined by individual pharmacies. Due to safety requirements, some medications are dispensed as originally packaged by the manufacturer and we cannot make adjustments to the packaged quantity or otherwise open or split packages to create 22, 30, and 90-day supplies of those medications. In most cases, refills cannot be obtained until 75% of the prescription has been used. Controlled substances cannot be refilled until 80% of the prescription has been used. Controlled substances are medications that can cause physical and mental dependence, and have restrictions on how they can be filled and refilled. They are regulated and classified by the DEA (Drug Enforcement Administration) based on how likely they are to cause dependence. Call us or visit our website if you have any questions about dispensing limits. Please note that in the event of a national or other emergency, or if you are a reservist or National Guard member who is called to active military duty, you should contact us regarding your prescription drug needs. See the contact information below.
Note: Benefits for certain self-injectable (self-administered) drugs are provided only when they are dispensed by a pharmacy under the pharmacy benefit. Medical benefits will be provided for a once-per-lifetime dose per therapeutic category of drugs dispensed by your provider or any non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B coverage. See pages 114-115 for Tier 4 and Tier 5 specialty drug fills from a Preferred pharmacy.
Note: Benefits for certain auto-immune infusion medications (Remicade, Renflexis and Inflectra) are provided only when obtained by a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center). See Drugs From Other Sources in this Section, page 120, for more information.
Standard Option: Subject to manufacturer packaging and your prescriber’s instructions, you may purchase up to a 90-day supply of covered drugs and supplies through the Retail Pharmacy Program. You may purchase a supply of more than 21 days up to 90 days through the Mail Service Prescription Drug Program for a single copayment.
Basic Option: When you fill Tier 1 (generic), Tier 2 (preferred brand-name), and Tier 3 (non-preferred brand-name) prescriptions at a Preferred retail pharmacy, you may purchase up to a 30-day supply for a single copayment, or up to a 90-day supply for additional copayments unless otherwise noted. Members with primary Medicare Part B coverage may purchase a supply of more than 21 days up to 90 days through the Mail Service Prescription Drug Program for a single copayment.
Under Standard Option and Basic Option
Benefits for Tier 4 and Tier 5 specialty drugs purchased at a retail 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. 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 90-day supply after the third fill of the specialty drug. See page 116 for more information.
Note: Certain drugs such as narcotics may have additional limits or requirements as established by the U.S. FDA or by national scientific or medical practice guidelines (such as Centers for Disease Control and Prevention, American Medical Association, etc.) on the quantities that a pharmacy may dispense. In addition, pharmacy dispensing practices are regulated by the state where they are located and may also be determined by individual pharmacies. Due to safety requirements, some medications are dispensed as originally packaged by the manufacturer and we cannot make adjustments to the packaged quantity or otherwise open or split packages to create 22, 30, and 90-day supplies of those medications. In most cases, refills cannot be obtained until 75% of the prescription has been used. Controlled substances cannot be refilled until 80% of the prescription has been used. Controlled substances are medications that can cause physical and mental dependence, and have restrictions on how they can be filled and refilled. They are regulated and classified by the DEA (Drug Enforcement Administration) based on how likely they are to cause dependence. Call us or visit our website if you have any questions about dispensing limits. Please note that in the event of a national or other emergency, or if you are a reservist or National Guard member who is called to active military duty, you should contact us regarding your prescription drug needs. See the contact information below.
Note: Benefits for certain self-injectable (self-administered) drugs are provided only when they are dispensed by a pharmacy under the pharmacy benefit. Medical benefits will be provided for a once-per-lifetime dose per therapeutic category of drugs dispensed by your provider or any non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B coverage. See pages 114-115 for Tier 4 and Tier 5 specialty drug fills from a Preferred pharmacy.
Note: Benefits for certain auto-immune infusion medications (Remicade, Renflexis and Inflectra) are provided only when obtained by a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center). See Drugs From Other Sources in this Section, page 120, for more information.
• Important contact information
Retail Pharmacy Program: 800-624-5060, TTY: 711;
Mail Service Prescription Drug Program: 800-262-7890, TTY: 711;
Specialty Drug Pharmacy Program: 888-346-3731, TTY: 711; or www.fepblue.org.
Retail Pharmacy Program: 800-624-5060, TTY: 711;
Mail Service Prescription Drug Program: 800-262-7890, TTY: 711;
Specialty Drug Pharmacy Program: 888-346-3731, TTY: 711; or www.fepblue.org.
Patient Safety and Quality Monitoring (PSQM)
We have a special program to promote patient safety and monitor healthcare quality. Our Patient Safety and Quality Monitoring (PSQM) program features a set of closely aligned programs that are designed to promote the safe and appropriate use of medications. Examples of these programs include:
We have a special program to promote patient safety and monitor healthcare quality. Our Patient Safety and Quality Monitoring (PSQM) program features a set of closely aligned programs that are designed to promote the safe and appropriate use of medications. Examples of these programs include:
- Prior approval – As described on page 107, this program requires that approval be obtained for certain prescription drugs and supplies before we provide benefits for them.
- Safety checks – Before your prescription is filled, we perform quality and safety checks for usage precautions, drug interactions, drug duplication, excessive use, and frequency of refills.