2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 107
Section 5(f). Prescription Drug Benefits
Page 107
Benefit Description
Covered Medications and Supplies (cont.)
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.
Note: Benefits for the first three fills of each Tier 4 or Tier 5 specialty drug are limited to a 30-day supply. Benefits are available for a 31 to 90-day supply after the third fill.
Note: Due to manufacturer restrictions, a small number of specialty drugs may only be available through a Preferred retail pharmacy. You will be responsible for paying only the copayments shown here for specialty drugs affected by these restrictions.
Contact Us: If you have any questions about this program, or need assistance with your specialty drug orders, please call 888-346-3731, TTY: 711.
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)
When Medicare Part B is primary, you pay the following:
Tier 4 (preferred specialty drug): $80 copayment for each purchase of up to a 30-day supply ($210 copayment for a 31 to 90-day supply)
Tier 5 (non-preferred specialty drug): $100 copayment for each purchase of up to a 30-day supply ($255 copayment for a 31 to 90-day supply)
Covered Medications and Supplies (cont.)
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.
Note: Benefits for the first three fills of each Tier 4 or Tier 5 specialty drug are limited to a 30-day supply. Benefits are available for a 31 to 90-day supply after the third fill.
Note: Due to manufacturer restrictions, a small number of specialty drugs may only be available through a Preferred retail pharmacy. You will be responsible for paying only the copayments shown here for specialty drugs affected by these restrictions.
Contact Us: If you have any questions about this program, or need assistance with your specialty drug orders, please call 888-346-3731, TTY: 711.
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)
When Medicare Part B is primary, you pay the following:
Tier 4 (preferred specialty drug): $80 copayment for each purchase of up to a 30-day supply ($210 copayment for a 31 to 90-day supply)
Tier 5 (non-preferred specialty drug): $100 copayment for each purchase of up to a 30-day supply ($255 copayment for a 31 to 90-day supply)
Benefit Description
Asthma Medications
Preferred 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% of the Plan allowance (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): $35 copayment for each purchase of up to a 30-day supply ($105 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
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, 4 and 5 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 - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $75 copayment
Asthma Medications
Preferred 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% of the Plan allowance (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): $35 copayment for each purchase of up to a 30-day supply ($105 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
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, 4 and 5 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 - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $75 copayment
Covered Medication and Supplies - continued on next page