2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(f). Prescription Drug Benefits
Covered Medications and Supplies
Section 5. Benefits
Section 5(f). Prescription Drug Benefits
Covered Medications and Supplies
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.
Benefits Description
Covered Medications and Supplies
Asthma Medications
Preferred Retail Pharmacies:
Note: See Section 3 for information about drugs and supplies that require prior approval.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): 20% of the Plan allowance (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
Tier 2 (preferred brand-name drug): $35 copayment for each purchase of up to a 30-day supply ($105 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $30 copayment for each purchase of up to a 30-day supply ($90 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program:
Note: You must obtain prior approval for certain drugs before Mail Service will fill your prescription. See Section 3.
Note: See earlier in this section for Tier 3, 4 and 5 prescription drug benefits.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $65 copayment (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $75 copayment
Benefits Description
Covered Medications and Supplies
Asthma Medications
Preferred Retail Pharmacies:
Note: See Section 3 for information about drugs and supplies that require prior approval.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): 20% of the Plan allowance (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
Tier 2 (preferred brand-name drug): $35 copayment for each purchase of up to a 30-day supply ($105 copayment for a 31 to 90-day supply)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $30 copayment for each purchase of up to a 30-day supply ($90 copayment for a 31 to 90-day supply)
Mail Service Prescription Drug Program:
Note: You must obtain prior approval for certain drugs before Mail Service will fill your prescription. See Section 3.
Note: See earlier in this section for Tier 3, 4 and 5 prescription drug benefits.
Standard Option - You Pay
Tier 1 (generic drug): $5 copayment (no deductible)
Tier 2 (preferred brand-name drug): $65 copayment (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Tier 2 (preferred brand-name drug): $75 copayment