2023 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
Note: A prescription and prior approval are required for medical foods provided under the pharmacy benefit. Renewals of the prior authorization are required every benefit year for inborn errors of metabolism and tube feeding.
Note: See Section 5(a), page 58, for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube under the medical benefit.
- Drugs, vitamins and minerals, and nutritional supplements that by Federal law of the United States require a prescription for their purchase
Note: See pages 112-113 for our coverage of medications to promote better health as recommended under the Affordable Care Act.
- Medical foods, as defined by the U.S. Food and Drug Administration, that are consumed or administered enterally and are intended for the specific dietary management of a disease or condition for which there are distinctive nutritional requirements.
The Plan covers medical food formulas and enteral nutrition products that are ordered by a healthcare provider, and are medically necessary to prevent clinical deterioration in members at nutritional risk. (See Coverage below)
- Must meet the definition of medical food (see definition on page 155)
- Must be receiving active, regular, and ongoing medical supervision and must be unable to manage the condition by modification of diet alone
- Must meet the definition of medical food (see definition on page 155)
Coverage is provided as follows:
- Inborn errors of amino acid metabolism
- Food allergy with atopic dermatitis, gastrointestinal symptoms, IgE mediation, malabsorption disorder, seizure disorder, failure to thrive, or prematurity, when administered orally and is the sole source (100%) of nutrition. This once per lifetime benefit is limited to one year following the date of the initial prescription or physician order for the medical food (e.g., Neocate, in a formula form or powders mixed to become formulas)
- Medical foods and nutritional supplements when administered by catheter or nasogastric tubes
Note: A prescription and prior approval are required for medical foods provided under the pharmacy benefit. Renewals of the prior authorization are required every benefit year for inborn errors of metabolism and tube feeding.
Note: See Section 5(a), page 58, for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube under the medical benefit.
- Insulin, diabetic test strips, lancets, and tubeless insulin delivery systems
Note: See page 58 for our coverage of insulin pumps with tubes.
- Needles and disposable syringes for the administration of covered medications
- Clotting factors and anti-inhibitor complexes for the treatment of hemophilia
Standard Option - You Pay
See page 108 and pages 110-116
Basic Option - You Pay
See page 108 and pages 110-116
Benefits Description
Note: We waive your cost-share for generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative, when you purchase them at a Preferred retail pharmacy or, for Standard Option members and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. See pages 115 and 116 for details.
Standard Option - You Pay
See below and pages 111-117
Basic Option - You Pay
See below and pages 111-117
- Drugs to aid smoking and tobacco cessation that require a prescription by Federal law
Note: We provide benefits for over-the-counter (OTC) smoking and tobacco cessation medications only as described on page 117.
Note: You may be eligible to receive smoking and tobacco cessation medications at no charge. See page 117 for more information.
- Drugs for the diagnosis and treatment of infertility, except as described on pages 118-119
- Drugs to treat gender dysphoria (gonadotropin-releasing hormone (GnRH) antagonists and testosterones)
- Contraceptive drugs and devices, limited to:
- Diaphragms and contraceptive rings
- Injectable contraceptives
- Intrauterine devices (IUDs)
- Implantable contraceptives
- Oral and transdermal contraceptives
- Diaphragms and contraceptive rings
Note: We waive your cost-share for generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative, when you purchase them at a Preferred retail pharmacy or, for Standard Option members and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. See pages 115 and 116 for details.
Standard Option - You Pay
See below and pages 111-117
Basic Option - You Pay
See below and pages 111-117