2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits
Page 95

Benefits Description

Covered Medications and Supplies (cont.)
 

• 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

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. 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
Continued from previous page:

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)

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