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
Benefits 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 drug) $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 drug) $50 copayment for each purchase of up to a 90-day supply