2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f)(a). FEP Medicare Prescription Drug Plan
Page 120
Section 5(f)(a). FEP Medicare Prescription Drug Plan
Page 120
Benefit Description
Covered Medications and Supplies (cont.)
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.
Standard Option - You Pay
Basic Option - You Pay
Covered Medications and Supplies (cont.)
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.
Standard Option - You Pay
Basic Option - You Pay
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.
- Products and foods other than liquid formulas or powders mixed to become formulas; foods and formulas readily available in a retail environment and marketed for persons without medical conditions; low-protein modified foods (e.g., pastas, breads, rice, sauces and baking mixes); nutritional supplements, energy products; and similar items
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 Medications and Supplies - continued on next page