2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 105
Section 5(f). Prescription Drug Benefits
Page 105
Benefit Description
Mail Service Prescription Drug Program
For Standard Option and Basic Option members when Medicare Part B is Primary, if your doctor orders more than a 21-day supply of covered drugs or supplies, up to a 90-day supply, you can use this service for your prescriptions and refills.
Please refer to Section 7 for instructions on how to use the 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: Not all drugs are available through the Mail Service Prescription Drug Program. There are no specialty drugs available through the Mail Service Program.
Note: Please keep reading for information about the Specialty Drug Pharmacy Program.
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, as 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.
If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.
Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.
Note: For additional Family Planning benefits, see Section 5(a).
Standard Option - You Pay
Tier 1 (generic drug): $15 copayment (no deductible)
Note: You pay a $10 copayment per generic prescription filled (and/or refill ordered) when Medicare Part B is primary.
Note: You may be eligible to receive your first 4 generic prescriptions filled (and/or refills ordered) at no charge when you change from certain brand-name drugs to a corresponding generic drug replacement, as previously stated.
Tier 2 (preferred brand-name drug): $90 copayment (no deductible)
Tier 3 (non-preferred brand-name drug): $125 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $20 copayment
Tier 2 (preferred brand-name drug): $100 copayment
Tier 3 (non-preferred brand-name drug): $125 copayment
When Medicare Part B is not primary: No benefits
Note: Although you do not have access to the Mail Service Prescription Drug Program, you may request home delivery of prescription drugs you purchase from Preferred retail pharmacies offering options for online ordering.
Mail Service Prescription Drug Program
For Standard Option and Basic Option members when Medicare Part B is Primary, if your doctor orders more than a 21-day supply of covered drugs or supplies, up to a 90-day supply, you can use this service for your prescriptions and refills.
Please refer to Section 7 for instructions on how to use the 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: Not all drugs are available through the Mail Service Prescription Drug Program. There are no specialty drugs available through the Mail Service Program.
Note: Please keep reading for information about the Specialty Drug Pharmacy Program.
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, as 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.
If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.
Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.
Note: For additional Family Planning benefits, see Section 5(a).
Standard Option - You Pay
Tier 1 (generic drug): $15 copayment (no deductible)
Note: You pay a $10 copayment per generic prescription filled (and/or refill ordered) when Medicare Part B is primary.
Note: You may be eligible to receive your first 4 generic prescriptions filled (and/or refills ordered) at no charge when you change from certain brand-name drugs to a corresponding generic drug replacement, as previously stated.
Tier 2 (preferred brand-name drug): $90 copayment (no deductible)
Tier 3 (non-preferred brand-name drug): $125 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $20 copayment
Tier 2 (preferred brand-name drug): $100 copayment
Tier 3 (non-preferred brand-name drug): $125 copayment
When Medicare Part B is not primary: No benefits
Note: Although you do not have access to the Mail Service Prescription Drug Program, you may request home delivery of prescription drugs you purchase from Preferred retail pharmacies offering options for online ordering.
Benefit Description
Specialty Drug Pharmacy Program
We cover specialty drugs that are listed on the Service Benefit Plan Specialty Drug List. This list is subject to change. For the most up-to-date list, call the phone number below or visit our website, www.fepblue.org. (See Section 10 for the definition of "specialty drugs.")
Each time you order a new specialty drug or refill, a Specialty Drug pharmacy representative will work with you. See Section 7 for more details about the Program.
Standard Option - You Pay
Tier 4 (preferred specialty drug): $65 copayment for each purchase of up to a 30-day supply ($185 copayment for a 31 to 90-day supply) (no deductible)
Tier 5 (non-preferred specialty drug): $85 copayment for each purchase of up to a 30-day supply ($240 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 4 (preferred specialty drug): $120 copayment for each purchase of up to a 30-day supply ($350 copayment for a 31 to 90-day supply)
Tier 5 (non-preferred specialty drug): $200 copayment for each purchase of up to a 30-day supply ($500 copayment for a 31 to 90-day supply)
Specialty Drug Pharmacy Program
We cover specialty drugs that are listed on the Service Benefit Plan Specialty Drug List. This list is subject to change. For the most up-to-date list, call the phone number below or visit our website, www.fepblue.org. (See Section 10 for the definition of "specialty drugs.")
Each time you order a new specialty drug or refill, a Specialty Drug pharmacy representative will work with you. See Section 7 for more details about the Program.
Standard Option - You Pay
Tier 4 (preferred specialty drug): $65 copayment for each purchase of up to a 30-day supply ($185 copayment for a 31 to 90-day supply) (no deductible)
Tier 5 (non-preferred specialty drug): $85 copayment for each purchase of up to a 30-day supply ($240 copayment for a 31 to 90-day supply) (no deductible)
Basic Option - You Pay
Tier 4 (preferred specialty drug): $120 copayment for each purchase of up to a 30-day supply ($350 copayment for a 31 to 90-day supply)
Tier 5 (non-preferred specialty drug): $200 copayment for each purchase of up to a 30-day supply ($500 copayment for a 31 to 90-day supply)
Covered Medication and Supplies - continued on next page