2024 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits
MPDP Covered Drugs and Supplies

 

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.