2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits
Page 100
Section 5(f). Prescription Drug Benefits
Page 100
Benefits Description
Covered Medications and Supplies (cont.)
Not covered:
You Pay
All charges
Covered Medications and Supplies (cont.)
Not covered:
- Drugs purchased through the mail or internet from pharmacies inside or outside the United States by members located in the United States
- Over-the-counter (OTC) contraceptive drugs and devices, except as described on page 95
- Drugs used to terminate pregnancy
- Sublingual allergy desensitization drugs, except as described on page 48
You Pay
All charges
Benefits Description
Drugs From Other Sources
Covered prescription drugs and supplies not obtained at a retail pharmacy or through the Specialty Drug Pharmacy Program to include, but not limited to:
Note: Prior approval is required for certain high-cost drugs obtained outside one of our pharmacy programs. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/highcostdrugs for a list of these drugs. See page 20 for more information on prior approval.
You Pay
Preferred professional providers and facilities: 30% of the Plan allowance (deductible applies)
Non-preferred professional providers (Participating/Non-participating) and Non-preferred facilities (Member/Non-member): You pay all charges
Drugs From Other Sources
Covered prescription drugs and supplies not obtained at a retail pharmacy or through the Specialty Drug Pharmacy Program to include, but not limited to:
- Physician’s office – for more information refer to Section 5(a)
- Facility (inpatient or outpatient) – for more information refer to Section 5(c)
- Hospice agency – for more information refer to Section 5(c)
- Drugs obtained at a physician’s office, inpatient or outpatient facility or hospice agency while overseas, see Section 5(i)
- Drugs and supplies covered only under the medical benefit, see auto-immune infusions below
- Prescription drugs obtained from a Preferred retail pharmacy, that are billed by a skilled nursing facility, nursing home, or extended care facility, see page 97
Note: Prior approval is required for certain high-cost drugs obtained outside one of our pharmacy programs. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/highcostdrugs for a list of these drugs. See page 20 for more information on prior approval.
You Pay
Preferred professional providers and facilities: 30% of the Plan allowance (deductible applies)
Non-preferred professional providers (Participating/Non-participating) and Non-preferred facilities (Member/Non-member): You pay all charges
Benefits Description
Auto-immune infusion medications: Remicade, Renflexis and Inflectra
Note: Benefits for certain auto-immune infusion medications (limited to Remicade, Renflexis and Inflectra) are covered only when they are obtained by a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center).
You Pay
Preferred professional providers and facilities: 30% of the Plan allowance (deductible applies)
Non-preferred professional providers (Participating/Non-participating) and Non-preferred facilities (Member/Non-member): You pay all charges
Auto-immune infusion medications: Remicade, Renflexis and Inflectra
Note: Benefits for certain auto-immune infusion medications (limited to Remicade, Renflexis and Inflectra) are covered only when they are obtained by a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center).
You Pay
Preferred professional providers and facilities: 30% of the Plan allowance (deductible applies)
Non-preferred professional providers (Participating/Non-participating) and Non-preferred facilities (Member/Non-member): You pay all charges