2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits
Page 95


Note: The calendar year deductible does not apply to covered prescription drugs unless specifically stated "(deductible applies)".
 
Benefits Description

Covered Medications and Supplies

Preferred retail pharmacies

Preferred Generic Drugs obtained at Preferred retail and overseas retail pharmacies:

Tier 1


Notes:

 
  • See Section 5(i), page 110, for information on how to file claims for overseas services.
     
  • For prescription drugs billed for by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on this page for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy.

You Pay
Preferred retail and overseas retail pharmacy:

 
  • $5 copayment for each purchase of up to a 30-day supply
     
  • $15 copayment for each purchase of a 31 to 90-day supply

Non-preferred pharmacy: You pay all charges
 
Benefit Description

Preferred Brand-Name Drugs obtained at Preferred retail and overseas retail pharmacies:

Tier 2


Notes:

 
  • See Section 5(i), page 110, for information on how to file claims for overseas services.
     
  • For prescription drugs billed for by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on this page for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy.

You Pay
Preferred retail and overseas retail pharmacy:

 
  • 40% of the Plan allowance (up to a $350 maximum) for each purchase of up to a 30-day supply
     
  • 40% of the Plan allowance (up to a $1,050 maximum) for each purchase of up to a 90-day supply

Non-preferred pharmacy: You pay all charges
 
Benefit Description

Preferred specialty drugs (generic and brand-name) obtained at Preferred retail and overseas retail pharmacies:

Tier 2
  • Benefits for specialty drugs purchased at a Preferred retail pharmacy are limited to one purchase of up to a 30-day supply for each prescription dispensed.

Notes:
 
  • All refills must be obtained through the Specialty Drug Pharmacy Program. See page 100 for more information.
     
  • See the Specialty Drug Pharmacy Program for applicable cost-shares and limits on page 100.
     
  • Due to safety requirement, some medications are dispensed as originally packaged by the manufacturer and we cannot make adjustment to the packaged quantity or otherwise open or split packages to create a 30-day supply of these medications.
     
  • For prescription drugs billed for by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on this page for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy.
     
  • See Section 5(i), page 110, for information on how to file claims for overseas services.

You Pay
Preferred retail and overseas retail pharmacy:

 
  • 40% of the Plan allowance (up to a $350 maximum) for each purchase of up to a 30-day supply
     
  • If a 31 to 90-day supply of a specialty drug has to be dispensed due to manufacturer packaging, you pay 40% of the Plan allowance (up to a $1,050 maximum) for each purchase.

Non-preferred pharmacy: You pay all charges
 
Covered Medications and Supplies - continued on next page