2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 107
Section 5(f). Prescription Drug Benefits
Page 107
Benefit Description
Other Preferred Diabetic Medications, Test Strips, and Supplies
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 2 (preferred diabetic medications and supplies): 20% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 2 (preferred insulins): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply) (no deductible)
Non-preferred retail pharmacies: You pay all charges
Basic Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 2 (preferred brand-name drugs): $30 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program:
Note: See earlier in this section for Tier 2, 3, 4, and 5 prescription drug benefits.
Benefits will be provided for syringes, pens and pen needles and test strips at Tier 2 (diabetic medications and supplies) for Standard Option members, and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program.
Standard Option - You Pay
Tier 2 (preferred brand-name drug): $40 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 2 (preferred brand-name drugs) $50 copayment for each purchase of up to a 90-day supply
Other Preferred Diabetic Medications, Test Strips, and Supplies
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 2 (preferred diabetic medications and supplies): 20% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)
Tier 2 (preferred insulins): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply) (no deductible)
Non-preferred retail pharmacies: You pay all charges
Basic Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 2 (preferred brand-name drugs): $30 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program:
Note: See earlier in this section for Tier 2, 3, 4, and 5 prescription drug benefits.
Benefits will be provided for syringes, pens and pen needles and test strips at Tier 2 (diabetic medications and supplies) for Standard Option members, and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program.
Standard Option - You Pay
Tier 2 (preferred brand-name drug): $40 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 2 (preferred brand-name drugs) $50 copayment for each purchase of up to a 90-day supply
Benefit Description
Diabetic Meter Program
Members with diabetes may obtain one glucose meter kit every 365 days at no cost through our Diabetic Meter Program. To use this program, you must call the phone number listed below and request one of the eligible types of meters. The types of glucose meter kits available through the program are subject to change.
To order your free glucose meter kit, call us toll-free at 855-582-2024, Monday through Friday, from 9 a.m. to 7 p.m., Eastern Time, or visit our website at www.fepblue.org. The selected meter kit will be sent to you within 7 to 10 days of your request.
Note: Contact your physician to obtain a new prescription for the test strips and lancets to use with the new meter.
Standard Option - You Pay
Nothing for a glucose meter kit ordered through the Diabetic Meter Program
Basic Option - You Pay
Nothing for a glucose meter kit ordered through the Diabetic Meter Program
Diabetic Meter Program
Members with diabetes may obtain one glucose meter kit every 365 days at no cost through our Diabetic Meter Program. To use this program, you must call the phone number listed below and request one of the eligible types of meters. The types of glucose meter kits available through the program are subject to change.
To order your free glucose meter kit, call us toll-free at 855-582-2024, Monday through Friday, from 9 a.m. to 7 p.m., Eastern Time, or visit our website at www.fepblue.org. The selected meter kit will be sent to you within 7 to 10 days of your request.
Note: Contact your physician to obtain a new prescription for the test strips and lancets to use with the new meter.
Standard Option - You Pay
Nothing for a glucose meter kit ordered through the Diabetic Meter Program
Basic Option - You Pay
Nothing for a glucose meter kit ordered through the Diabetic Meter Program