2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f)(a). FEP Medicare Prescription Drug Plan
Page 114
Section 5(f)(a). FEP Medicare Prescription Drug Plan
Page 114
Benefit Description
Covered Medication and Supplies (cont.)
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, 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).
Note: For a list of the Network Long-Term Care pharmacies, call 888-338-7737, TTY: 711.
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
Tier 4 (preferred specialty drug): $75 copayment for each purchase of up to a 30-day supply; ($195 for 31 to 90-day supply)
Covered Medication and Supplies (cont.)
- Drugs prescribed to treat obesity (prior approval required)
- Contraceptive drugs and devices, limited to:
- Diaphragms and contraceptive rings
- Injectable contraceptives
- Intrauterine devices (IUDs)
- Implantable contraceptives
- Oral and transdermal contraceptives
- Diaphragms and contraceptive rings
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, 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).
- 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
Note: For a list of the Network Long-Term Care pharmacies, call 888-338-7737, TTY: 711.
Standard Option - You Pay
See previous page
Basic Option - You Pay
Continued from previous page:
Tier 4 (preferred specialty drug): $75 copayment for each purchase of up to a 30-day supply; ($195 for 31 to 90-day supply)
Benefit Description
Mail Service Prescription Drug Program
For members enrolled in the FEP Medicare Prescription Drug Program, 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.
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)
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
Mail Service Prescription Drug Program
For members enrolled in the FEP Medicare Prescription Drug Program, 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.
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)
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 Medications and Supplies - continued on next page