2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits
Covered Medications and Supplies
Preferred retail pharmacies
Section 5(f). Prescription Drug Benefits
Covered Medications and Supplies
Preferred retail pharmacies
Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.
Benefits Description
Covered Medications and Supplies
Preferred retail pharmacies
Covered drug and supplies, such as:
Notes:
You Pay
Tier 1 Preferred Generic Drugs obtained at Preferred retail pharmacies:
Non-preferred pharmacy: You pay all charges
Tier 2 Preferred Brand-Name Drugs obtained at Preferred retail pharmacies:
Non-preferred pharmacy: You pay all charges
Preferred Specialty Drugs (generic and brand-name) obtained at Preferred retail pharmacies and through the Specialty Drug Pharmacy Program:
Non-preferred pharmacy: You pay all charges
Benefits Description
Covered Medications and Supplies
Preferred retail pharmacies
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 (prior approval required)
- 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
Notes:
- 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. 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.
- For additional Family Planning benefits, see Section 5(a).
- 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.
- Each time you order a new specialty drug or refill, a Specialty Drug pharmacy representative will work with you to arrange a delivery time and location that are most convenient for you, as well as ask you about any side effects you may be experiencing. See Section 7 for more details about the Program.
- We cover specialty drugs that are listed on the FEP Blue Focus Specialty Drug List. This list is subject to change. For the most up-to-date list, call the phone number below or visit our website, www.fepblue.org. (See Section 10 for the definition of "specialty drugs.")
You Pay
Tier 1 Preferred Generic Drugs obtained at Preferred retail pharmacies:
- $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
Tier 2 Preferred Brand-Name Drugs obtained at Preferred retail pharmacies:
- 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
Preferred Specialty Drugs (generic and brand-name) obtained at Preferred retail pharmacies and through the Specialty Drug Pharmacy Program:
- 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