2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f)(a). FEP Medicare Prescription Drug Program
Page 95
Section 5(f)(a). FEP Medicare Prescription Drug Program
Page 95
Benefits Description
Covered Medications and Supplies (cont.)
Note: We waive your cost-share for available forms of generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative, as listed in each therapeutic class under the HRSA guidelines, when purchased from a Preferred retail pharmacy. You may seek an exception for any contraceptive that is not available with zero-member cost-share. Your provider will need to complete the Contraceptive Exception Form under Pharmacy Forms found on our website at www.fepblue.org/claim-forms. If you have questions about the exception process, call 800-624-5060. If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.
Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.
Note: For additional Family Planning benefits, see Section 5(a).
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
Covered Medications and Supplies (cont.)
Note: We waive your cost-share for available forms of generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative, as listed in each therapeutic class under the HRSA guidelines, when purchased from a Preferred retail pharmacy. You may seek an exception for any contraceptive that is not available with zero-member cost-share. Your provider will need to complete the Contraceptive Exception Form under Pharmacy Forms found on our website at www.fepblue.org/claim-forms. If you have questions about the exception process, call 800-624-5060. If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.
Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.
Note: For additional Family Planning benefits, see Section 5(a).
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)
The pharmacy benefits starting here to the end of the section apply to all covered members, unless otherwise noted.