2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 116
Section 5(f). Prescription Drug Benefits
Page 116
Benefits Description
Covered Medication and Supplies (cont.)
Note: Our vaccine network is a network of Preferred retail pharmacies that have agreements with us to administer one or more routine immunizations. Check with your pharmacy or call our Retail Pharmacy Program at 800-624-5060, TTY: 711, to find out which vaccines your pharmacy can provide.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Covered Medication and Supplies (cont.)
Note: Our vaccine network is a network of Preferred retail pharmacies that have agreements with us to administer one or more routine immunizations. Check with your pharmacy or call our Retail Pharmacy Program at 800-624-5060, TTY: 711, to find out which vaccines your pharmacy can provide.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Benefits Description
Metformin and metformin extended release (excluding osmotic and modified release generic drugs)
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Mail Service Prescription Drug Program:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Metformin and metformin extended release (excluding osmotic and modified release generic drugs)
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Mail Service Prescription Drug Program:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Benefits Description
Medications to promote better health as recommended under the Patient Protection and Affordable Care Act (the “Affordable Care Act”), limited to:
Note: Benefits are not available for acetaminophen, ibuprofen, naproxen, etc.
Note: Benefits for these medications are subject to the dispensing limitations described earlier and are limited to recommended prescribed limits.
Note: To receive benefits, you must use a Preferred retail pharmacy and present a written prescription from your physician to the pharmacist.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
Medications to promote better health as recommended under the Patient Protection and Affordable Care Act (the “Affordable Care Act”), limited to:
- Iron supplements for children from age 6 months through 12 months
- Oral fluoride supplements for children from age 6 months through 5 years
- Folic acid supplements, 0.4 mg to 0.8 mg, for individuals capable of pregnancy
- Low-dose aspirin (81 mg per day) for pregnant members at risk for preeclampsia
- Aspirin for men age 45 through 79 and women age 50 through 79
- Generic cholesterol-lowering statin drugs
Note: Benefits are not available for acetaminophen, ibuprofen, naproxen, etc.
Note: Benefits for these medications are subject to the dispensing limitations described earlier and are limited to recommended prescribed limits.
Note: To receive benefits, you must use a Preferred retail pharmacy and present a written prescription from your physician to the pharmacist.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
Covered Medication and Supplies - continued on next page