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2024 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits
Page 95

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

Benefits Description

Covered Medications and Supplies
Covered drug and supplies, such as:

Drugs, vitamins and minerals, and nutritional supplements that by federal law of the United States require a prescription for their purchase.
Drugs for the diagnosis and treatment of infertility
Drugs for IVF - limited to 3 cycles annually (prior approval required)

Note: Drugs for the treatment of IVF must be purchased through the pharmacy drug program and you must meet our definition of infertility

Drugs associated with covered artificial insemination procedures
Drugs to treat gender dysphoria (gonadotropin releasing hormone (GnRH) antagonists and testosterones)
Contraceptive drugs and devices, limited to:
- Diaphragms and contraceptive rings
- Injectable contraceptives
- Intrauterine devices (IUDs)
- Implantable contraceptives
- Oral and transdermal contraceptives

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 when purchased at a network retail pharmacy.

Medical foods
Insulin, diabetic test strips, lancets, and tubeless insulin delivery systems (See Section 5(a) for our coverage of insulin pumps with tubes.)
Needles and disposable syringes for the administration of covered medications
Clotting factors and anti-inhibitor complexes for the treatment of hemophilia

You Pay
Tier 1: Preferred Generic Drugs obtained at a Retail Pharmacy

$5 copayment for each purchase of up to a 30-day supply (no deductible)
$15 copayment for each purchase of a 31 to 90-day supply (no deductible)

Tier 2: Preferred Brand-name Drugs obtained at a Retail Pharmacy

40% of the Plan allowance (up to a $350 maximum) for each purchase of up to a 30-day supply (no deductible)
40% of the Plan allowance (up to a $1,050 maximum) for each purchase of a 31 to 90-day supply (no deductible)

Tier 3: Non-preferred Brand-name Drugs obtained at a Retail Pharmacy

40% of the Plan allowance (up to a $350 maximum) for each purchase of up to a 30-day supply (no deductible)
40% of the Plan allowance (up to a $1,050 maximum) for each purchase of a 31 to 90-day supply (no deductible)

Tier 4: Preferred Specialty Drugs obtained at a Retail Pharmacy

40% of the Plan allowance (up to a $350 maximum) for each purchase of up to a 30-day supply (no deductible)
40% of the Plan allowance (up to a $1,050 maximum) for each purchase of a 31 to 90-day supply (no deductible)

The pharmacy benefits starting here to the end of the section apply to all covered members, unless otherwise noted.

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