PSHB Standard and Basic Options
2026 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f)(a). FEP Medicare Prescription Drug Plan
Page 119
Section 5(f)(a). FEP Medicare Prescription Drug Plan
Page 119
Benefits Description
Covered Medications and Supplies (cont.)
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.
Note: Our vaccine network is a network of Preferred retail pharmacies that have agreements with us to administer one or more routine immunizations. Check with your pharmacy or call our Retail Pharmacy Program at 800-624-5060, TTY: 711, to find out which vaccines your pharmacy can provide.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Covered Medications and Supplies (cont.)
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.
Note: Our vaccine network is a network of Preferred retail pharmacies that have agreements with us to administer one or more routine immunizations. Check with your pharmacy or call our Retail Pharmacy Program at 800-624-5060, TTY: 711, to find out which vaccines your pharmacy can provide.
Standard Option - You Pay
Preferred retail pharmacy: Nothing (no deductible)
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Basic Option - You Pay
Preferred retail pharmacy: Nothing
Non-preferred retail pharmacy: You pay all charges (except as noted below)
Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.
Benefits Description
Metformin and metformin extended release (excluding osmotic and modified release generic drugs)
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Mail Service Prescription Drug Program:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - When Medicare Part B is primary, and you are enrolled in the Medicare Prescription Drug Program, you pay the following:
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Metformin and metformin extended release (excluding osmotic and modified release generic drugs)
Preferred Retail Pharmacies:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Mail Service Prescription Drug Program:
Standard Option - You Pay
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)
Basic Option - When Medicare Part B is primary, and you are enrolled in the Medicare Prescription Drug Program, you pay the following:
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply
Benefits Description
Medications to promote better health as recommended under the Patient Protection and Affordable Care Act (the “Affordable Care Act”), limited to:
Note: Benefits are not available for acetaminophen, ibuprofen, naproxen, etc.
Note: Benefits for these medications are subject to the dispensing limitations described earlier and are limited to recommended prescribed limits.
Note: To receive benefits, you must use a Preferred retail pharmacy and present a written prescription from your physician to the pharmacist.
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
Medications to promote better health as recommended under the Patient Protection and Affordable Care Act (the “Affordable Care Act”), limited to:
- Iron supplements for children from age 6 months through 12 months
- Oral fluoride supplements for children from age 6 months through 5 years
- Folic acid supplements, 0.4 mg to 0.8 mg, for individuals capable of pregnancy
- Low-dose aspirin (81 mg per day) for pregnant members at risk for preeclampsia
- Aspirin for men age 45 through 79 and women age 50 through 79
- Generic cholesterol-lowering statin drugs
Note: Benefits are not available for acetaminophen, ibuprofen, naproxen, etc.
Note: Benefits for these medications are subject to the dispensing limitations described earlier and are limited to recommended prescribed limits.
Note: To receive benefits, you must use a Preferred retail pharmacy and present a written prescription from your physician to the pharmacist.
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 - continued on next page