2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f)(a). FEP Medicare Prescription Drug Plan
Page 117
Section 5(f)(a). FEP Medicare Prescription Drug Plan
Page 117
Benefits Description
Covered Medications and Supplies (cont.)
Smoking and Tobacco Cessation Medications
Note: To receive benefits for over-the-counter (OTC) smoking and tobacco cessation medications, you must have a physician’s prescription for each OTC medication that must be filled by a pharmacist at a Preferred retail pharmacy.
Note: These benefits apply only when all of the criteria listed above are met. Regular prescription drug benefits will apply to purchases of smoking and tobacco cessation medications not meeting these criteria. Benefits are not available for over-the-counter (OTC) smoking and tobacco cessation medications except as described above.
Note: See Section 5(a) for our coverage of smoking and tobacco cessation treatment, counseling, and classes.
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 (cont.)
Smoking and Tobacco Cessation Medications
- Continued from previous page:
- Varenicline starting pack
- Varenicline starting pack
- Brand-name medications available by prescription:
- Nicotrol cartridge inhaler
- Nicotrol NS Spray 10 mg/ml
- Nicotrol cartridge inhaler
- Over-the-counter (OTC) medications
Note: To receive benefits for over-the-counter (OTC) smoking and tobacco cessation medications, you must have a physician’s prescription for each OTC medication that must be filled by a pharmacist at a Preferred retail pharmacy.
Note: These benefits apply only when all of the criteria listed above are met. Regular prescription drug benefits will apply to purchases of smoking and tobacco cessation medications not meeting these criteria. Benefits are not available for over-the-counter (OTC) smoking and tobacco cessation medications except as described above.
Note: See Section 5(a) for our coverage of smoking and tobacco cessation treatment, counseling, and classes.
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
Benefits Description
Covered Medications and Supplies (cont.)
Anti-hypertensive 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): $3 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
Mail Service Prescription Drug Program:
Note: You must obtain prior approval for certain drugs before Mail Service will fill your prescription.
Note: See earlier in this section for Tier 2, 3, 4, and 5 prescription drug benefits.
Standard Option - You Pay
Tier 1 (generic drug): $3 copayment (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Covered Medications and Supplies (cont.)
Anti-hypertensive 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): $3 copayment (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply
Mail Service Prescription Drug Program:
Note: You must obtain prior approval for certain drugs before Mail Service will fill your prescription.
Note: See earlier in this section for Tier 2, 3, 4, and 5 prescription drug benefits.
Standard Option - You Pay
Tier 1 (generic drug): $3 copayment (no deductible)
Basic Option - When Medicare Part B is primary, you pay the following:
Tier 1 (generic drug): $5 copayment
Benefits Description
Note: We provide benefits in full for OTC contraceptive drugs and devices when the contraceptives meet U.S. FDA standards for OTC products. To receive benefits, you must use a retail pharmacy and present the pharmacist with a written prescription from your physician.
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
- Over-the-counter (OTC) contraceptive drugs and devices, limited to:
- Emergency contraceptive pills
- Condoms
- Spermicides
- Sponges
- Emergency contraceptive pills
Note: We provide benefits in full for OTC contraceptive drugs and devices when the contraceptives meet U.S. FDA standards for OTC products. To receive benefits, you must use a retail pharmacy and present the pharmacist with a written prescription from your physician.
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
Benefits Description
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network (see below) and administered in compliance with applicable state law and pharmacy certification requirements.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network (see below) and administered in compliance with applicable state law and pharmacy certification requirements.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Covered Medications and Supplies - continued on next page