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2024 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits
Page 89

Must be receiving active, regular, and ongoing medical supervision and must be unable to manage the condition by modification of diet alone.

Coverage is provided as follows:

Inborn errors of amino acid metabolism
Food allergy with atopic dermatitis, gastrointestinal symptoms, IgE mediation, malabsorption disorder, seizure disorder, failure to thrive, or prematurity, when administered orally and is the sole source (100%) of nutrition. This once per lifetime benefit is limited to one year following the date of the initial prescription or physician order for the medical food (e.g., Neocate, in a formula form or powders mixed to become formulas)
Medical foods and nutritional supplements when administered by catheter or nasogastric tubes

Notes:

A prescription and prior approval are required for medical foods provided under the pharmacy benefit. Renewals of the prior authorization are required every benefit year for inborn errors of metabolism and tube feeding.
See Section 5(a) for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube under the medical benefit.

Here is how to obtain your prescription drugs and supplies:

Make sure you have your ID card when you are ready to purchase your prescription.
Go to any Preferred retail pharmacy, or
Visit the website of your Preferred retail pharmacy to request your prescriptions online and delivery, if available.

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

Benefits Description

Covered Medications and Supplies
Preferred retail pharmacies

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 generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative, when you purchase them at a Preferred retail pharmacy.

You Pay
Tier 1 Preferred Generic Drugs obtained at Preferred retail pharmacies:

$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)

Non-preferred pharmacy: You pay all charges

Tier 2 Preferred Brand-Name Drugs obtained at Preferred retail pharmacies:

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 up to a 90-day supply (no deductible)

Non-preferred pharmacy: You pay all charges

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