2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 118
Section 5(f). Prescription Drug Benefits
Page 118
Benefit Description
Covered Medication and Supplies (cont.)
For more information, consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose or call SAMHSA's National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/.
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a combined 90-day supply through any of our pharmacy programs, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Covered Medication and Supplies (cont.)
For more information, consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose or call SAMHSA's National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/.
Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a combined 90-day supply through any of our pharmacy programs, all Tier 1 fills thereafter are subject to the corresponding cost-share.
Benefits Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Remicade, Renflexis, and Inflectra are not covered for prescriptions obtained from a retail pharmacy, Mail Service Prescription or through the Specialty Drug Program
- Medical supplies such as dressings and antiseptics
- Drugs and supplies for cosmetic purposes
- Supplies for weight loss
- Drugs for orthodontic care, dental implants, and periodontal disease
- Drugs used in conjunction with non-covered assisted reproductive technology (ART) and assisted insemination procedures
- Drugs used in conjunction with IVF that exceed the covered 3 per year annual cycle limitation described in this section
- Insulin and diabetic supplies except when obtained from a retail pharmacy or through the Mail Service Prescription Drug Program, or except when Medicare Part B is primary or you are enrolled in the FEP Medicare Prescription Drug Program (see Section 5(a))
- Medications and orally taken nutritional supplements that do not require a prescription under Federal law even if your doctor prescribes them or if a prescription is required under your state law
Note: See previous benefits in this section for our coverage of medications recommended under the Affordable Care Act and for smoking and tobacco cessation medications.
- Medical foods administered orally are not covered if not obtained at a retail pharmacy or through the Mail Service Prescription Drug Program
Note: See Section 5(a) for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Covered Medication and Supplies - continued on next page