2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits
Page 94
Section 5(f). Prescription Drug Benefits
Page 94
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 does not accumulate toward the out-of-pocket catastrophic protection maximum described in Section 4.
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 does not accumulate toward the out-of-pocket catastrophic protection maximum described in Section 4.
Medical Foods
Medical foods, as defined by the U.S. Food and Drug Administration, that are consumed or administered enterally and are intended for the specific dietary management of a disease or condition for which there are distinctive nutritional requirements.
The Plan covers medical food formulas and enteral nutrition products that are ordered by a healthcare provider and are medically necessary to prevent clinical deterioration in members at nutritional risk.
Must meet the definition of medical food described in Section 10.
Must be receiving active, regular, and ongoing medical supervision and must be unable to manage the condition by modification of diet alone.
Coverage is provided as follows:
Notes:
Medical foods, as defined by the U.S. Food and Drug Administration, that are consumed or administered enterally and are intended for the specific dietary management of a disease or condition for which there are distinctive nutritional requirements.
The Plan covers medical food formulas and enteral nutrition products that are ordered by a healthcare provider and are medically necessary to prevent clinical deterioration in members at nutritional risk.
Must meet the definition of medical food described in Section 10.
Must be receiving active, regular, and ongoing medical supervision and must be unable to manage the condition by modification of diet alone.
Coverage is provided as follows:
- Inborn errors of amino acid metabolism
- Food allergy with atopic dermatitis, gastrointestinal symptoms, IgE mediation, malabsorption disorder, seizure disorder, failure to thrive, or prematurity, when administered orally and is the sole source (100%) of nutrition. This once per lifetime benefit is limited to one year following the date of the initial prescription or physician order for the medical food (e.g., Neocate, in a formula form or powders mixed to become formulas)
- Medical foods and nutritional supplements when administered by catheter or nasogastric tubes
Notes:
- A prescription is required for medical foods provided under the pharmacy benefit.
- See Section 5(a) for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube under the medical benefit.
Here is how to obtain your prescription drugs and supplies:
- Make sure you have your ID card when you are ready to purchase your prescription.
- Go to any network pharmacy, or
- Visit the website of your retail pharmacy to request your prescriptions online and delivery, if available.
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:
Note: Drugs for the treatment of IVF must be purchased through the pharmacy drug program and you must meet our definition of infertility.
You Pay
Tier 1: Preferred Generic 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
Note: Drugs for the treatment of IVF must be purchased through the pharmacy drug program and you must meet our definition of infertility.
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)
Covered Medication and Supplies - continued on next page