2027 Blue Cross and Blue Shield Service Benefit Plan
FEP Blue Standard and FEP Blue Basic
Section 5(f)(a). FEP Medicare Prescription Drug Program
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.

Benefits Description

Covered Medications and Supplies
Retail Pharmacies

Covered drugs 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
    Note: Drugs used for IVF must be purchased through the pharmacy drug program and you must meet our definition of infertility.
     
  • Drugs associated with covered artificial insemination procedures
     
  • Drugs prescribed to treat obesity (prior approval required)
     
  • 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 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 found at https://www.hrsa.gov/womens-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. Once we have been contacted with exception request information sufficient for us to make a determination, you will receive a response within 24 hours or the next business day. Contraceptive exception requests are not subject to Section 8, The Disputed Claims Process. If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.
       
  • Medical foods
     
  • Needles and disposable syringes for the administration of covered medications
     
  • Clotting factors and anti-inhibitor complexes for the treatment of hemophilia

Note: For a list of the Network Long-Term Care pharmacies, call 888-338-7737, TTY: 711.


Standard Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 30-day supply ($15 copayment for a 31 to 90-day supply) (no deductible)

Tier 2 (preferred brand-name drug): $35 copayment for each purchase of up to a 30-day supply ($105 copayment for a 31 to 90-day supply) (no deductible)

Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)

Tier 4 (specialty drug): $60 copayment for each purchase of up to a 30-day supply ($180 copayment for a 31 to 90-day supply) (no deductible)

Basic Option - You Pay
Tier 1 (generic drug): $10 copayment for each purchase of up to a 30-day supply ($30 copayment for a 31 to 90-day supply)

Tier 2 (preferred brand-name drug): $45 copayment for each purchase of up to a 30-day supply ($135 copayment for a 31 to 90-day supply)

Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance for each purchase of up to a 31 to 90-day supply

Tier 4 (specialty drug): $75 copayment for each purchase of up to a 30-day supply; ($195 for 31 to 90-day supply)