2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f)(a). FEP Medicare Prescription Drug Plan
Page 116
Section 5(f)(a). FEP Medicare Prescription Drug Plan
Page 116
Benefit Description
Covered Medications and Supplies (cont.)
Other Preferred Diabetic Medications, Test Strips, and Supplies
Network Retail Pharmacies:
Standard Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $20 copayment for each purchase of up to a 30-day supply ($50 copayment for a 31 to 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)
Basic Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $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, and 4 prescription drug benefits.
Benefits will be provided for syringes, pens and pen needles and test strips at Tier 2 (diabetic medications and supplies) for those enrolled in the FEP Medicare Prescription Drug Program when obtained 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 - You Pay
Tier 2 (preferred brand-name drugs): $50 copayment for each purchase of up to a 90-day supply
Covered Medications and Supplies (cont.)
Other Preferred Diabetic Medications, Test Strips, and Supplies
Network Retail Pharmacies:
Standard Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $20 copayment for each purchase of up to a 30-day supply ($50 copayment for a 31 to 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)
Basic Option - You Pay
Tier 2 (preferred diabetic medications and supplies): $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, and 4 prescription drug benefits.
Benefits will be provided for syringes, pens and pen needles and test strips at Tier 2 (diabetic medications and supplies) for those enrolled in the FEP Medicare Prescription Drug Program when obtained 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 - You Pay
Tier 2 (preferred brand-name drugs): $50 copayment for each purchase of up to a 90-day supply
The pharmacy benefits starting here to the end of the section apply to all covered members, unless otherwise noted.
Benefits Description
Covered Medications and Supplies
Smoking and Tobacco Cessation Medications
If you are a covered member, you may be eligible to obtain specific prescription generic and brand-name smoking and tobacco cessation medications at no charge. Additionally, you may be eligible to obtain over-the-counter (OTC) smoking and tobacco cessation medications, prescribed by your physician, at no charge. These benefits are only available when you use a Preferred retail pharmacy. To qualify, create a Tobacco Cessation Quit Plan using Daily Habits. For more information, see Section 5(h). The Quit Plan is not required for those covered under the FEP Medicare Prescription Drug Program.
Note: There may be age-restrictions based on U.S. FDA guidelines for these medications.
The following medications are covered through this program:
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
Covered Medications and Supplies
Smoking and Tobacco Cessation Medications
If you are a covered member, you may be eligible to obtain specific prescription generic and brand-name smoking and tobacco cessation medications at no charge. Additionally, you may be eligible to obtain over-the-counter (OTC) smoking and tobacco cessation medications, prescribed by your physician, at no charge. These benefits are only available when you use a Preferred retail pharmacy. To qualify, create a Tobacco Cessation Quit Plan using Daily Habits. For more information, see Section 5(h). The Quit Plan is not required for those covered under the FEP Medicare Prescription Drug Program.
Note: There may be age-restrictions based on U.S. FDA guidelines for these medications.
The following medications are covered through this program:
- Generic medications available by prescription:
- Bupropion ER 150 mg tablet
- Bupropion SR 150 mg tablet
- Varenicline 0.5 mg tablets
- Varenicline 1 mg tablets
- Bupropion ER 150 mg tablet
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges
Covered Medications and Supplies - continued on next page