2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f)(a). FEP Medicare Prescription Drug Program
Page 94
Section 5(f)(a). FEP Medicare Prescription Drug Program
Page 94
- Disclosure of information. As part of our administration of prescription drug benefits, we may disclose information about your prescription drug utilization, including the names of your prescribing physicians, to any treating physicians or dispensing pharmacies.
- Important contact information
FEP Medicare Prescription Drug Program: 888-338-7737, TTY 711
- PDP EGWP Catastrophic Maximums
Each individual enrolled in the FEP Medicare Prescription Drug Program has a separate and lower out-of-pocket catastrophic protection maximum for the drugs purchased while covered under this Program.
This separate catastrophic maximum is $2,000.
This amount accumulates toward the out-of-pocket catastrophic protection maximum described in Section 4.
Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.
Benefits Description
Covered Medications and Supplies
Covered drug and supplies, such as:
You Pay
Tier 1: Preferred Generic Drugs obtained at a Retail Pharmacy
Tier 2: Preferred Brand-name Drugs obtained at a Retail Pharmacy
Tier 3: Non-preferred Brand-name Drugs obtained at a Retail Pharmacy
Tier 4: Preferred Specialty Drugs obtained at a Retail Pharmacy
Benefits Description
Covered Medications and Supplies
Covered drug and supplies, such as:
- Drugs, vitamins and minerals, and nutritional supplements that by federal law of the United States require a prescription for their purchase.
- Drugs for the diagnosis and treatment of infertility
- Drugs for IVF - limited to 3 cycles annually
- Drugs associated with covered artificial insemination procedures
- Drugs to treat gender dysphoria (gonadotropin releasing hormone (GnRH) antagonists and testosterones)
- Drugs prescribed to treat obesity (prior approval required)
- 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
- Contraceptive drugs and devices, limited to:
- Diaphragms and contraceptive rings
- Injectable contraceptives
- Intrauterine devices (IUDs)
- Implantable contraceptives
- Oral and transdermal contraceptives
You Pay
Tier 1: Preferred Generic Drugs obtained at a 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)
Tier 2: Preferred Brand-name Drugs obtained at a 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 a 31 to 90-day supply (no deductible)
Tier 3: Non-preferred Brand-name Drugs obtained at a 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 a 31 to 90-day supply (no deductible)
Tier 4: Preferred Specialty Drugs obtained at a 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 a 31 to 90-day supply (no deductible)