Document Number:
SB24.05f.41
Revision #:
v1.0
Date Published:
1/1/2024
2024 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
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, 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, you pay the following:
Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply