2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 104
Section 5(f). Prescription Drug Benefits
Page 104
- Under Standard Option,
- You may use the Retail Pharmacy Program, the Mail Service Prescription Drug Program, or the Specialty Drug Pharmacy Program to fill your prescriptions.
- There is no calendar year deductible for the Retail Pharmacy Program, the Mail Service Prescription Drug Program, or the Specialty Drug Pharmacy Program.
- PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.
- You may use the Retail Pharmacy Program, the Mail Service Prescription Drug Program, or the Specialty Drug Pharmacy Program to fill your prescriptions.
- Under Basic Option,
- You must use Preferred retail pharmacies or the Specialty Drug Pharmacy Program in order to receive benefits. Our specialty drug pharmacy is a Preferred pharmacy.
- The Mail Service Prescription Drug Program is available only to members with primary Medicare Part B coverage.
- There is no calendar year deductible.
- We use a managed formulary for certain drug classes.
- You must use Preferred retail pharmacies or the Specialty Drug Pharmacy Program in order to receive benefits. Our specialty drug pharmacy is a Preferred pharmacy.
We will send each new enrollee a Plan identification card, which covers pharmacy and medical benefits. Standard Option members, and Basic Option members with primary Medicare Part B coverage, are eligible to use the Mail Service Prescription Drug Program and will also receive a mail service order form and a pre-addressed reply envelope.
There are important features you should be aware of. These include:
• Who can write your prescriptions. A physician or dentist licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, or, in states that permit it, a licensed/certified provider with prescriptive authority prescribing within their scope of practice must write your prescriptions. See Section 5(i) for drugs purchased overseas.
• Where you can obtain them.
There are important features you should be aware of. These include:
• Who can write your prescriptions. A physician or dentist licensed in the United States, Puerto Rico, or the U.S. Virgin Islands, or, in states that permit it, a licensed/certified provider with prescriptive authority prescribing within their scope of practice must write your prescriptions. See Section 5(i) for drugs purchased overseas.
• Where you can obtain them.
Under Standard Option, you may fill prescriptions at a Preferred retail pharmacy, at a Non-preferred retail pharmacy, through our Mail Service Prescription Drug Program, or through the Specialty Drug Pharmacy Program. Under Standard Option, we pay a higher level of benefits when you use a Preferred retail pharmacy, our Mail Service Prescription Drug Program, or the Specialty Drug Pharmacy Program. See page 159 for the definition of “specialty drugs.”
Under Basic Option, you must fill prescriptions only at a Preferred retail pharmacy or through the Specialty Drug Pharmacy Program, in order to receive benefits. If Medicare Part B is your primary coverage, you may also fill prescriptions through our Mail Service Prescription Drug Program. See page 159 for the definition of “specialty drugs.”
Under Standard Option and Basic Option
Note: The Mail Service Prescription Drug Program will not fill your prescription for a drug requiring prior approval until you have obtained prior approval. CVS Caremark, the program administrator, will hold your prescription for you up to 30 days. If prior approval is not obtained within 30 days, your prescription will be unable to be filled and a letter will be mailed to you explaining the prior approval procedures.
Note: The Specialty Drug Pharmacy Program will not fill your prescription for a drug requiring prior approval until you have obtained prior approval. CVS Caremark, the program administrator, will hold your prescription for you up to 30 days. If prior approval is not obtained within 30 days, your prescription will be unable to be filled and a letter will be mailed to you explaining the prior approval procedures.
Note: Both Preferred and Non-preferred retail pharmacies may offer options for ordering prescription drugs online. Drugs ordered online may be delivered to your home; however, these online orders are not a part of the Mail Service Prescription Drug Program, described on pages 115-116.
Note: Due to manufacturer restrictions, a small number of specialty drugs used to treat rare or uncommon conditions may be available only through a Preferred retail pharmacy. See pages 114-115 for information about your cost-share for specialty drugs purchased at a Preferred retail pharmacy that are affected by these restrictions.
Under Basic Option, you must fill prescriptions only at a Preferred retail pharmacy or through the Specialty Drug Pharmacy Program, in order to receive benefits. If Medicare Part B is your primary coverage, you may also fill prescriptions through our Mail Service Prescription Drug Program. See page 159 for the definition of “specialty drugs.”
Under Standard Option and Basic Option
Note: The Mail Service Prescription Drug Program will not fill your prescription for a drug requiring prior approval until you have obtained prior approval. CVS Caremark, the program administrator, will hold your prescription for you up to 30 days. If prior approval is not obtained within 30 days, your prescription will be unable to be filled and a letter will be mailed to you explaining the prior approval procedures.
Note: The Specialty Drug Pharmacy Program will not fill your prescription for a drug requiring prior approval until you have obtained prior approval. CVS Caremark, the program administrator, will hold your prescription for you up to 30 days. If prior approval is not obtained within 30 days, your prescription will be unable to be filled and a letter will be mailed to you explaining the prior approval procedures.
Note: Both Preferred and Non-preferred retail pharmacies may offer options for ordering prescription drugs online. Drugs ordered online may be delivered to your home; however, these online orders are not a part of the Mail Service Prescription Drug Program, described on pages 115-116.
Note: Due to manufacturer restrictions, a small number of specialty drugs used to treat rare or uncommon conditions may be available only through a Preferred retail pharmacy. See pages 114-115 for information about your cost-share for specialty drugs purchased at a Preferred retail pharmacy that are affected by these restrictions.