2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 114
Section 5(f). Prescription Drug Benefits
Page 114
Benefits Description
Covered Medications and Supplies (cont.)
Opioid Reversal Agents (cont.)
Mail Service Prescription Drug Program
Standard Option - You Pay
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year (no deductible)
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Covered Medications and Supplies (cont.)
Opioid Reversal Agents (cont.)
Mail Service Prescription Drug Program
Standard Option - You Pay
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year (no deductible)
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.
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.
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)
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.
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)
Covered Medications and Supplies - continued on next page