2026 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 2. Changes for 2026
Page 16

 

  • Your copayment for outpatient observation services performed and billed by a hospital or freestanding ambulatory facility is now a $425 copayment per day for up to $2,975. (See page 78.)
     
  • 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 81.)
     
  • 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 pages 89-91.)
     
  • 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 ($150 maximum) for each purchase of up to a 30-day supply ($400 maximum for a 31 to 90-day supply). (See page 102.)
     
  • For members enrolled in our regular pharmacy drug program who also have Medicare Part B primary, your responsibility for a Tier 2 (preferred brand-name drug) is now 35% of the Plan allowance ($100 maximum) for each purchase of up to a 30-day supply ($300 maximum for a 31 to 90-day supply). (See page 103.)
     
  • For members enrolled in our regular pharmacy drug program who have Medicare Part B primary, your responsibility for a Tier 2 (preferred brand-name drug) purchased through the Mail Service Prescription Drug Program is now 35% of the Plan allowance up to a $225 maximum. (See page 104.)
     
  • For members enrolled in our regular pharmacy drug program who have Medicare Part B primary, your responsibility for a Tier 3 (non-preferred brand-name drug) purchased through the Mail Service Prescription Drug Program is now 35% of the Plan allowance up to a $250 maximum. (See page 104.)
     
  • Your cost for the 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 is now 60% of the Plan allowance for each purchase of up to a 90-day supply. (See page 102).
     
  • 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 ($250 maximum) for a purchase of up to a 30-day supply. (See page 102.)
     
  • For members enrolled in our regular pharmacy drug program who have Medicare Part B primary, your responsibility for a Tier 4 (preferred specialty drug) obtained from a Preferred retail pharmacy is now 35% of the Plan allowance ($200 maximum) for a purchase of up to a 30-day supply. (See page 103.)
     
  • For members enrolled in our regular pharmacy drug program, your responsibility for a Tier 4 (preferred specialty drug) obtained from the Specialty Drug Pharmacy Program is now 35% of the Plan allowance ($250 maximum) limited to one purchase of up to 30-day supply ($700 for a 31 to 90-day supply). (See page 105.)
     
  • For members enrolled in our regular pharmacy drug program who also have Medicare Part B primary, your responsibility for a Tier 4 (preferred specialty drug) is now 35% of the Plan allowance ($200 maximum) for a purchase of up to a 30-day supply ($450 maximum for a 31 to 90-day supply) when obtained through the Specialty Drug Pharmacy Program. (See page 105.)
     
  • 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 ($500 maximum) for a purchase of up to a 30-day supply. (See page 102.)
     
  • For members enrolled in our regular pharmacy drug program who have Medicare Part B primary, your responsibility for a Tier 5 (non-preferred specialty drug) obtained at a Preferred retail pharmacy is now 35% of the Plan allowance ($450 maximum) limited to up to a 30-day supply. (See page 103.)
     
  • 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 ($500 maximum) limited to up to a 30-day supply ($850 for a 31 to 90-day supply). (See page 105.)
     
  • For members enrolled in our regular pharmacy drug program who have Medicare Part B primary, your responsibility for a Tier 5 (non-preferred specialty drug) is now 35% of the Plan allowance ($450 maximum) limited to up to a 30-day supply ($625 maximum for up to a 90-day supply) when obtained through the Specialty Drug Pharmacy Program. (See page 105.)
     
  • 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 118.)
     
  • Your cost-share to treat an accidental dental injury is now 35% of the Plan allowance. (See page 120.)