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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
Page 97

Benefits Description

Covered Medications and Supplies (cont.)
We cover the first prescription filled for certain bowel preparation medications for colorectal cancer screenings with no member cost-share. We also cover certain antiretroviral therapy medications for HIV for those at risk but who do not have HIV. You can view the list of covered medications on our website at www.fepblue.org or call 800-624-5060, TTY: 711, for assistance.

You Pay
Preferred retail and overseas retail pharmacy: Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges

Benefits Description
Opioid Reversal Agents: Tier 1 medications limited to generic naloxone nasal spray and injectable

You Pay
Preferred retail and overseas retail pharmacy: Nothing for the purchase of one 90-day supply per calendar year (no deductible)

Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.

Non-preferred retail pharmacy: You pay all charges

Benefits Description
Here is how to obtain your prescription drugs and supplies:

Preferred Retail Pharmacies

Make sure you have your ID card when you are ready to purchase your prescription.
Go to any Preferred retail pharmacy, or
Visit the website of your Preferred retail pharmacy to request your prescriptions online and delivery, if available.
For a listing of Preferred retail pharmacies, call the Retail Pharmacy Program at 800-624-5060, TTY: 711, or visit our website, www.fepblue.org.

Notes:

Benefits for Tier 2 specialty drugs purchased at a Preferred retail pharmacy are limited to one purchase of up to a 30-day supply for each prescription dispensed. All refills must be obtained through the Specialty Drug Pharmacy Program, see page 98 for more information.
Retail pharmacies that are Preferred for prescription drugs are not necessarily Preferred for durable medical equipment (DME) and medical supplies. To receive Preferred benefits for DME and covered medical supplies, you must use a Preferred DME or medical supply provider. See Section 5(a) for the benefit levels that apply to DME and medical supplies.
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.
For a list of the Preferred Network Long Term Care pharmacies, call 800-624-5060, TTY: 711.
For coordination of benefits purposes, if you need a statement of Preferred retail pharmacy benefits in order to file claims with your other coverage when this Plan is the primary payor, call the Retail Pharmacy Program at 800-624-5060, TTY: 711, or visit our website at www.fepblue.org.

You Pay
Preferred retail and overseas retail pharmacy:

Tier 1

$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)

Tier 2

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 a 31 to 90-day supply (no deductible)

Non-preferred pharmacy: You pay all charges

Covered Medications and Supplies - continued on next page

Go to page 96. Go to page 98.