2026 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 2. Changes for 2026
Page 18

 

  • There is no longer a reduced Tier 5 (non-preferred specialty drug) benefit for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary when obtained through the Specialty Drug Pharmacy Program. You will pay the same cost-share as those who are enrolled in our regular prescription drug program that do not have Medicare Part B primary. (See page 108.)
     
  • There is no longer a reduced Asthma medication Tier 1 (generic drug) benefit listed for members enrolled in our regular pharmacy drug program who have Medicare B as primary when obtained at a Preferred retail pharmacy. You will pay the same cost-share as those who are enrolled in our regular prescription drug program that do not have Medicare Part B primary. (See page 108.)
     
  • There is no longer a reduced Asthma medication Tier 2 (preferred brand-name drug) benefit for members enrolled in our regular pharmacy drug program who have Medicare B as primary when obtained at a Preferred retail pharmacy. You will pay the same cost-share as those who are enrolled in our regular prescription drug program that do not have Medicare Part B primary. (See page 108.)
     
  • There is no longer a separate Mail Service Prescription Drug Program for Tier 1 (generic drug) Asthma medications for members enrolled in our regular pharmacy drug program who have Medicare B as primary.
     
  • There is no longer a separate Mail Order Prescription Drug Program benefit for Tier 2 (preferred brand-name drug) Asthma medications for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary.
     
  • There is no longer a reduced Diabetic Medication, Test Strips, and Supplies Tier 2 (preferred brand-name drug) benefit for members enrolled in our regular pharmacy drug program who have Medicare B as primary when obtained at a Preferred retail pharmacy. You will pay the same cost-share as those who are enrolled in our regular pharmacy drug program that do not have Medicare Part B primary. (See page 108.)
     
  • There is no longer a separate Mail Order Prescription Drug Program benefit for Diabetic Medication, Test Strips, and Supplies Tier 2 (preferred brand-name drug) for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary.
     
  • There is no longer a separate Mail order Prescription Drug Program benefit for Tier 1 (generic drug) Anti-hypertensive Medications for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary.
     
  • There is no longer a separate Mail Order Prescription Drug Program benefit for Tier 1 (generic drug) Metformin and metformin extended release (excluding osmotic and modified release generic drugs) for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary.
     
  • There is no longer a separate Mail Order Prescription Drug Program benefit for generic medications to reduce breast cancer risk for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary.
     
  • There is no longer a separate Mail Order Prescription Drug Program benefit for bowel preparation and antiretroviral therapy medications for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary.
     
  • There is no longer a separate Mail Order Prescription Drug Program benefit for opioid reversal agents for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary.
     
  • Your cost-share for covered prescription drugs and supplies not obtained at a retail pharmacy or through the Specialty Drug Pharmacy Program, is now 35% of the Plan allowance. (See page 122.)
     
  • Your cost-share to treat an accidental dental injury is now 35% of the Plan allowance. (See page 125.)

Changes to both our Standard and Basic Options
 
  • Prior approval for genetic testing will be required when the test is being performed to assess the risk of passing a genetic condition to a child, or when the member has no active disease or signs or symptoms of the disease that is being screened. Prior approval is not required when a member has an active disease, signs and symptoms of a genetic condition that could be passed to a child, or when the test is needed to determine a course of treatment for a disease. (See page 24.)
     
  • Prior approval is now required for elective non-urgent outpatient surgical orthopedic procedures on the hip, knee, and spine. (See page 24.)
     
  • Prior approval for outpatient hospice care will no longer be required. (See pages 87-89.)
     
  • Your separate FEP Medicare Prescription Drug Catastrophic maximum is now $2,100. (See page 114.)
     
  • Surgical and pharmacy services related to sex-trait modifications are no longer covered under this program. (See page 139.)

 

Changes to both our Standard and Basic Options
 
  • Prior approval for genetic testing will be required when the test is being performed to assess the risk of passing a genetic condition to a child, or when the member has no active disease or signs or symptoms of the disease that is being screened. Prior approval is not required when a member has an active disease, signs and symptoms of a genetic condition that could be passed to a child, or when the test is needed to determine a course of treatment for a disease. (See page 24.)
     
  • Prior approval is now required for elective non-urgent outpatient surgical orthopedic procedures on the hip, knee, and spine. (See page 24.)
     
  • Prior approval for outpatient hospice care will no longer be required. (See pages 87-89.)
     
  • Your separate FEP Medicare Prescription Drug Catastrophic maximum is now $2,100. (See page 114.)
     
  • Surgical and pharmacy services related to sex-trait modifications are no longer covered under this program. (See page 139.)