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2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option – 2025
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PPO: $7.50 for each purchase of up to a 30-day supply generic ($5.00 for a 30-day supply if you have Medicare Part B primary)/30% of our allowance Preferred brand-name/50% of our allowance non-preferred brand-name
Non-PPO: 45% of our allowance (AWP)

Mail Service Prescription Drug Program:

$15 generic ($10 if you have Medicare Part B primary)/$90 Preferred brand-name/$125 non-preferred brand-name per prescription; up to a 90-day supply

Specialty Drug Pharmacy Program:

$65 preferred specialty drug for a purchase of up to a 30-day supply; $85 non-preferred specialty drug for a purchase of up to a 30-day supply

103-107

Dental care
Scheduled allowances for diagnostic and preventive services; regular benefits for dental services required due to accidental injury and covered oral and maxillofacial surgery
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Wellness and other special features: Health Tools; Blue Health Assessment; MyBlue® Customer eService; National Doctor and Hospital Finder; Healthy Families; travel benefit/services overseas; Care Management Programs; and Flexible benefits option
See Section 5(h).
125-129

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum)

Self Only: Nothing after $6,000 (PPO) or $8,000 (PPO/Non-PPO) per contract per year
Self Plus One: Nothing after $12,000 (PPO) or $16,000 (PPO/Non-PPO) per contract per year
Self and Family: Nothing after $12,000 (PPO) or $16,000 (PPO/Non-PPO) per contract per year

Note: Some costs do not count toward this protection.
Note: When one covered family member (Self Plus One and Self and Family contracts) reaches the Self Only maximum during the calendar year, that member’s claims will no longer be subject to associated member cost-share amounts for the remainder of the year. All remaining family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.
32-33

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