2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 119
Section 5(f). Prescription Drug Benefits
Page 119
Benefits Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Products and foods other than liquid formulas or powders mixed to become formulas; foods and formulas readily available in a retail environment and marketed for persons without medical conditions; low-protein modified foods (e.g., pastas, breads, rice, sauces and baking mixes); nutritional supplements, energy products; and similar items
Note: See Section 5(a) for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube.
- Infant formula other than previously described in this section and in Section 5(a)
- Drugs for which prior approval has been denied or not obtained
- Drugs and supplies related to sexual dysfunction or sexual inadequacy
- Drugs and covered-drug-related supplies for the treatment of gender dysphoria if not obtained from a retail pharmacy or through the Mail Service Prescription Drug Program or Specialty Drug Pharmacy Program as previously described in this section
- Drugs purchased through the mail or internet from pharmacies outside the United States by members located in the United States
- Over-the-counter (OTC) contraceptive drugs and devices, except as previously described in this section
- Drugs used to terminate pregnancy
- Sublingual allergy desensitization drugs, except as described in Section 5(a)
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefits Description
Drugs From Other Sources
Covered prescription drugs and supplies not obtained at a retail pharmacy, through the Specialty Drug Pharmacy Program, or, for Standard Option members and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. This includes drugs and supplies covered only under the medical benefit.
Note: Prior approval is required for certain medical benefit drugs that will be submitted on a medical claim for reimbursement. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/medicalbenefitdrugs for a list of these drugs. See Section 3 for more information on prior approval.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating professional provider: 35% of the Plan allowance (deductible applies)
Non-participating professional provider: 35% of the Plan allowance (deductible applies) plus any difference between our allowance and the billed amount
Member facilities: 35% of the Plan allowance (deductible applies)
Basic Option - You Pay
Preferred: 30% of the Plan allowance
Participating professional provider: You pay all charges
Non-participating professional provider: You pay all charges
Member/Non-member facilities: You pay all charges
Drugs From Other Sources
Covered prescription drugs and supplies not obtained at a retail pharmacy, through the Specialty Drug Pharmacy Program, or, for Standard Option members and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. This includes drugs and supplies covered only under the medical benefit.
Note: Prior approval is required for certain medical benefit drugs that will be submitted on a medical claim for reimbursement. Contact the customer service number on the back of your ID card or visit us at www.fepblue.org/medicalbenefitdrugs for a list of these drugs. See Section 3 for more information on prior approval.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating professional provider: 35% of the Plan allowance (deductible applies)
Non-participating professional provider: 35% of the Plan allowance (deductible applies) plus any difference between our allowance and the billed amount
Member facilities: 35% of the Plan allowance (deductible applies)
Basic Option - You Pay
Preferred: 30% of the Plan allowance
Participating professional provider: You pay all charges
Non-participating professional provider: You pay all charges
Member/Non-member facilities: You pay all charges
Drugs From Other Sources - continued on next page