Preferred retail pharmacies

This brochure version is for internal use only.

2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits

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 108, 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 (no deductible)
$15 copayment for each purchase of a 31 to 90-day supply (no deductible)

Non-preferred pharmacy: You pay all charges

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

Tier 2

Notes:

See Section 5(i), page 108, 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 (no deductible)
40% of the Plan allowance (up to a $1,050 maximum) for each purchase of up to a 90-day supply (no deductible)

Non-preferred pharmacy: You pay all charges

Benefits 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 98 for more information.
See the Specialty Drug Pharmacy Program for applicable cost-shares and limits on page 98.
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 108, 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 (no deductible)
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 (no deductible)

Non-preferred pharmacy: You pay all charges

Benefits Description

Tier 1 and 2 drugs purchased from a Preferred pharmacy include, but are not limited to the following:

Drugs, vitamins and minerals, and nutritional supplements included in our closed formulary that by Federal law of the United States require a prescription for their purchase

Note: See page 96 for our coverage of medications to promote better health as recommended under the Affordable Care Act.
Medical foods, as defined by the U.S. Food and Drug Administration, that are consumed or administered enterally and are intended for the specific dietary management of a disease or condition for which there are distinctive nutritional requirements.

The Plan covers medical food formulas and enteral nutrition products that are ordered by a healthcare provider, and are medically necessary to prevent clinical deterioration in members at nutritional risk. (See Coverage below)
- Must meet the definition of medical food (see definition on page 131)
- Must be receiving active, regular, and ongoing medical supervision and must be unable to manage the condition by modification of diet alone

Coverage is provided as follows:

Inborn errors of amino acid metabolism
Food allergy with atopic dermatitis, gastrointestinal symptoms, IgE mediation, malabsorption disorder, seizure disorder, failure to thrive, or prematurity, when administered orally and is the sole source (100%) of nutrition. This once per lifetime benefit is limited to one year following the date of the initial prescription or physician order for the medical food (e.g., Neocate, in a formula form or powders mixed to become formulas)
Medical foods and nutritional supplements when administered by catheter or nasogastric tubes

Notes:

A prescription and prior approval are required for medical foods provided under the pharmacy benefit. Renewals of the prior authorization are required every benefit year for inborn errors of metabolism and tube feeding.
See Section 5(a), page 54, for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube under the medical benefit.

Insulin, diabetic test strips, lancets and tubeless insulin delivery systems

Note: See page 53 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

You Pay
See pages 93 and 97

Benefits Description

Drugs to aid smoking and tobacco cessation that require a prescription by federal law

Notes:
- We provide benefits for over-the-counter (OTC) smoking and tobacco cessation medications only as described on page 98.
- You may be eligible to receive smoking and tobacco cessation medications at no charge. See page 98 for more information.
Drugs for the diagnosis of infertility, except as described on page 99
Drugs to treat gender dysphoria (gonadotropin-releasing hormone (GnRH) antagonists and testosterones)
Contraceptive drugs and devices, limited to:
- Diaphragms and contraceptive rings
- Injectable contraceptives
- Intrauterine devices (IUDs)
- Implantable contraceptives
- Oral and transdermal contraceptives

Note: We waive your cost-share for generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative, when you purchase them at a Preferred retail pharmacy.

You Pay
See pages 93 and 98