2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 113
Section 5(f). Prescription Drug Benefits
Page 113
Benefit Description
Covered Medication and Supplies (cont.)
listed in each therapeutic class under the HRSA guidelines found at https://www.hrsa.gov/womens-guidelines, when purchased from a Preferred retail pharmacy. You may seek an exception for any contraceptive that is not available with zero-member cost-share. Your provider will need to complete the Contraceptive Exception Form under Pharmacy Forms found on our website at www.fepblue.org/claim-forms. If you have questions about the exception process, call 800-624-5060.
Contact Us: If you have any questions about this program, or need assistance with your Mail Service drug orders, please call 800-262-7890, TTY: 711.
Note: If the cost of your prescription is less than your copayment, you pay only the cost of your prescription. The Mail Service Prescription Drug Program will charge you the lesser of the prescription cost or the copayment when you place your order. If you have already sent in your copayment, they will credit your account with any difference.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $85 copayment (no deductible)
Tier 3 (non-preferred brands): $125 copayment (no deductible)
Tier 4 (specialty-drugs): $150 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $15 copayment
Tier 2 (preferred brand-name drug): $95 copayment
Tier 3 (non-preferred brands): $125 copayment
Tier 4 (specialty-drugs): $150 copayment
Covered Medication and Supplies (cont.)
listed in each therapeutic class under the HRSA guidelines found at https://www.hrsa.gov/womens-guidelines, when purchased from a Preferred retail pharmacy. You may seek an exception for any contraceptive that is not available with zero-member cost-share. Your provider will need to complete the Contraceptive Exception Form under Pharmacy Forms found on our website at www.fepblue.org/claim-forms. If you have questions about the exception process, call 800-624-5060.
Contact Us: If you have any questions about this program, or need assistance with your Mail Service drug orders, please call 800-262-7890, TTY: 711.
Note: If the cost of your prescription is less than your copayment, you pay only the cost of your prescription. The Mail Service Prescription Drug Program will charge you the lesser of the prescription cost or the copayment when you place your order. If you have already sent in your copayment, they will credit your account with any difference.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $85 copayment (no deductible)
Tier 3 (non-preferred brands): $125 copayment (no deductible)
Tier 4 (specialty-drugs): $150 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $15 copayment
Tier 2 (preferred brand-name drug): $95 copayment
Tier 3 (non-preferred brands): $125 copayment
Tier 4 (specialty-drugs): $150 copayment
Benefit Description
Asthma Medications
Network Retail Pharmacies:
Note: See Section 3 for information about drugs and supplies that require prior approval.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $20 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
Tier 2 (preferred brand-name drug): $30 copayment for each purchase of up to a 30-day supply ($90 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program
Note: You must obtain prior approval for certain drugs before Mail Service will fill your prescription. See Section 3.
Note: See earlier in this section for Tier 3 and Tier 4 prescription drug benefits
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $65 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $75 copayment
Asthma Medications
Network Retail Pharmacies:
Note: See Section 3 for information about drugs and supplies that require prior approval.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $20 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
Tier 2 (preferred brand-name drug): $30 copayment for each purchase of up to a 30-day supply ($90 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program
Note: You must obtain prior approval for certain drugs before Mail Service will fill your prescription. See Section 3.
Note: See earlier in this section for Tier 3 and Tier 4 prescription drug benefits
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $65 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $75 copayment
Benefit Description
Other Preferred Diabetic Medications, Test Strips, and Supplies
Network Retail Pharmacies:
Standard Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $20 copayment for each purchase of up to a 30-day supply ($50 copayment for a 31 to 90-day supply) (no deductible)
Tier 2 (preferred insulins): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $30 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply)
Other Preferred Diabetic Medications, Test Strips, and Supplies
Network Retail Pharmacies:
Standard Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $20 copayment for each purchase of up to a 30-day supply ($50 copayment for a 31 to 90-day supply) (no deductible)
Tier 2 (preferred insulins): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $30 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply)
Covered Medication and Supplies - continued on next page