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

 

Section 2. Changes for 2026

 

This is the first year for the Postal Service Health Benefits Program. This Section is not an official statement of benefits. For that, go to Section 5 (Benefits).

 

Changes to our Standard Option only
 
  • There is no longer a reduced Preferred retail pharmacy Tier 1 (generic drug) benefit for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary. 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 when purchased from a Preferred retail pharmacy. (See page 105.)
     
  • There is no longer a reduced Tier 1 (generic drug) copayment for the Mail Service Prescription Drug Program for members enrolled in our regular prescription drug program who have Medicare Part B primary. You will pay the same cost-share as those enrolled in our regular prescription drug program who do not have Medicare Part B primary, when purchased through the Mail Service Prescription Drug Program. (See page 107.)
     
  • For members enrolled in our regular pharmacy drug program, you are now responsible for a $140 copay for a Tier 2 (preferred brand-name drug) purchased through the Mail Service Prescription Drug Program. (See page 107.)
     
  • For members enrolled in our regular pharmacy drug program, you are now responsible for $175 copay for Tier 3 (non-preferred brand-name drug) obtained through the Mail Order Service Prescription Drug Program. (See page 107.)
     
  • For members enrolled in our regular pharmacy drug program, your Tier 4 (preferred specialty drug) copayment will be $100 for each purchase up to a 30-day supply ($300 copay for 31 to 90-day supply), when purchased through the Specialty Drug Pharmacy Program. (See page 108.)
     
  • For members enrolled in our regular pharmacy drug program, your Tier 5 (non-preferred specialty drug) copayment will be $135 for each purchase up to a 30-day supply ($405 copay for 31 to 90-day supply), when purchased through the Specialty Drug Pharmacy Program. (See page 108.)
     
  • For members enrolled in our regular prescription drug program, certain asthma controller medications under our Tier 2 (preferred brand-name drug) are now only a $35 copayment for each purchase of up to a 30-day supply ($105 copayment for a 31 to 90-day supply) when purchased at a Preferred retail pharmacy. (See page 108.)

Changes to our Basic Option only
 
  • Your cost-share for oral and transdermal contraceptives is now 35% of the Plan allowance when obtained from a Preferred provider. (See page 52.)
     
  • Your cost share for reproductive services is now 35% of the Plan allowance when obtained from a Preferred provider. (See page 53.)
     
  • Your cost-share for certain vision services (testing, treatment and supplies) is now 35% of the Plan allowance when obtained from a Preferred provider. (See page 57.)
     
  • Your cost-share for orthopedic and prosthetic devices is now 35% of the Plan allowance when obtained from a Preferred provider. (See page 59.)
     
  • Your cost-share for durable medical equipment (DME) is now 35% of the Plan allowance when obtained from a Preferred provider. (See page 60.)
     
  • Your cost-share for medical supplies is now 35% of the Plan allowance when obtained from a Preferred provider. (See page 61.)
     
  • Your copayment for an inpatient admission is now a $425 per day copayment. (See pages 78, 85 and 97.)
     
  • The copayment associated with the charges incurred during delivery will be waived if you give birth in a Blue Distinction Center for Maternity. (See page 78.)
     
  • Your copayment for outpatient observation services performed and billed by a hospital or freestanding ambulatory facility is now a $425 per day copayment. (See page 81.)
     
  • Your cost share for outpatient drugs, medical devices, and durable medical equipment billed for by a Preferred facility is now 35% of the Plan allowance. (See page 84.)
     
  • Your cost-share for outpatient hospital emergency room services and supplies, including professional provider services, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by the hospital is now a $425 per day per facility copayment. (See page 93.)
     
  • There is no longer a reduced Tier 1 (generic drug) benefit for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary. 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 when purchased from a Preferred retail pharmacy. (See page 105.)
     
  • For members enrolled in our regular pharmacy drug program, your responsibility for a Tier 2 (preferred brand-name drug) is now 35% of the Plan allowance up to a maximum of $150 for purchases up to a 30-day supply and $450 for purchases 31-90 days. (See page 105.)
     
  • There is no longer a reduced Tier 2 (preferred brand name drug) benefit for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary. 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 when purchased from a Preferred retail pharmacy. (See page 105.)
     
  • There is no longer a separate Mail Order Prescription Drug Program Tier 1 (generic drug) benefit for members enrolled in our regular pharmacy drug program who have Medicare Part B primary.
     
  • There is no longer a separate Mail Order Prescription Drug Program Tier 2 (preferred brand-name drug) benefit for members enrolled in our regular pharmacy drug program who have Medicare Part B primary.
     
  • There is no longer a separate Mail Order Prescription Drug Program Tier 3 (non-preferred brand-name drug) benefit for members enrolled in our regular pharmacy drug program who have Medicare Part B primary.
     
  • There is no longer a reduced retail Tier 3 (non-preferred brand name drug) benefit for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary. 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 when purchased from a Preferred retail pharmacy. (See page 105).
     
  • For members enrolled in our regular pharmacy drug program, your responsibility for a Tier 4 (preferred specialty drug) obtained from a Preferred retail pharmacy is now 35% of the Plan allowance for a purchase of up to a 30-day supply up to a maximum of $400. (See page 105.)
     
  • There is no longer a reduced Tier 4 (preferred specialty drug) benefit for members enrolled in our regular pharmacy drug program who have Medicare Part B as primary. 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 105.)
     
  • Under the Specialty Drug Pharmacy Program, your responsibility for a Tier 4 (preferred specialty drug) obtained from the Specialty Drug Pharmacy Program is now 35% of the Plan allowance for a purchase of up to 30-day supply (up to a maximum of $400) and 31 to 90-day supply (up to a maximum of $1,200). (See page 108.)
     
  • There is no longer a reduced Tier 4 (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.)
     
  • For members enrolled in our regular pharmacy drug program, your responsibility for a Tier 5 (non-preferred specialty drug) obtained at a Preferred Retail Pharmacy is now 35% of the Plan allowance (up to a maximum of $500) limited to one purchase of up to a 30-day supply. (See page 105.)
     
  • 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 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 105.)
     
  • For members enrolled in our regular pharmacy drug program, your responsibility for a Tier 5 (non-preferred specialty drug) obtained through the Specialty Drug Pharmacy Program is now 35% of the Plan allowance for a 30-day supply (up to a maximum of $500) and a 31 to 90-day supply (up to a maximum of $1,500) when purchased through the Specialty Drug Pharmacy Program. (See page 108.)
     
  • 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.)