2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 120
Section 5(f). Prescription Drug Benefits
Page 120
Benefits Description
Drugs From Other Sources (cont.)
Note: We cover drugs and supplies purchased overseas as shown here, as long as they are the equivalent to drugs and supplies that by Federal law of the United States require a prescription. Please refer to Section 5(i) for more information.
Note: For covered prescription drugs and supplies purchased outside of the United States, Puerto Rico, and the U.S. Virgin Islands, please submit claims on an Overseas Claim Form. See Section 5(i) for information on how to file claims for overseas services.
Standard Option - You Pay
Continued from previous page:
Non-member facilities: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
See previous page
Drugs From Other Sources (cont.)
Note: We cover drugs and supplies purchased overseas as shown here, as long as they are the equivalent to drugs and supplies that by Federal law of the United States require a prescription. Please refer to Section 5(i) for more information.
Note: For covered prescription drugs and supplies purchased outside of the United States, Puerto Rico, and the U.S. Virgin Islands, please submit claims on an Overseas Claim Form. See Section 5(i) for information on how to file claims for overseas services.
- Please refer to the Sections indicated for additional benefit information related to drugs obtained from other sources:
- Physician’s office – Section 5(a)
- Facility (inpatient or outpatient) – Section 5(c)
- Hospice agency – Section 5(c)
- Physician’s office – Section 5(a)
- Please refer to information discussed previously in this section for prescription drugs obtained from a Preferred retail pharmacy, that are billed for by a skilled nursing facility, nursing home, or extended care facility.
Standard Option - You Pay
Continued from previous page:
Non-member facilities: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Basic Option - You Pay
See previous page
Benefits Description
For members covered under our regular pharmacy drug program:
Note: Benefits for certain auto-immune infusion medications (limited to Remicade, Renflexis and Inflectra) are covered only when they are obtained by a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center). Members covered under the FEP Medicare Prescription Drug Program may obtain these drugs under their pharmacy benefits.
Standard Option - You Pay
Preferred: 10% of the Plan allowance (deductible applies)
Participating professional provider: 15% of the Plan allowance (deductible applies)
Non-participating professional provider: 15% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Member facilities: 15% of the Plan allowance (deductible applies)
Non-member facilities: 15% of the Plan allowance (deductible applies), plus any difference between our allowance and billed amount.
Basic Option - You Pay
Preferred: 15% 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
For members covered under our regular pharmacy drug program:
- Auto-immune infusion medications: Remicade, Renflexis and Inflectra
Note: Benefits for certain auto-immune infusion medications (limited to Remicade, Renflexis and Inflectra) are covered only when they are obtained by a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center). Members covered under the FEP Medicare Prescription Drug Program may obtain these drugs under their pharmacy benefits.
Standard Option - You Pay
Preferred: 10% of the Plan allowance (deductible applies)
Participating professional provider: 15% of the Plan allowance (deductible applies)
Non-participating professional provider: 15% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Member facilities: 15% of the Plan allowance (deductible applies)
Non-member facilities: 15% of the Plan allowance (deductible applies), plus any difference between our allowance and billed amount.
Basic Option - You Pay
Preferred: 15% 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