2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(f). Prescription Drug Benefits
Page 118
Section 5(f). Prescription Drug Benefits
Page 118
Benefits Description
Covered Medications and Supplies (cont.)
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Covered Medications and Supplies (cont.)
Not covered:
- Remicade, Renflexis, and Inflectra are not covered for prescriptions obtained from a retail pharmacy, Mail Service Prescription or through the Specialty Drug Program
- Medical supplies such as dressings and antiseptics
- Drugs and supplies for cosmetic purposes
- Supplies for weight loss
- Drugs for orthodontic care, dental implants, and periodontal disease
- Drugs used in conjunction with assisted reproductive technology (ART) and assisted insemination procedures
- Insulin and diabetic supplies except when obtained from a retail pharmacy or through the Mail Service Prescription Drug Program, or except when Medicare Part B is primary (see pages 58 and 110)
- Medications and orally taken nutritional supplements that do not require a prescription under Federal law even if your doctor prescribes them or if a prescription is required under your state law
Note: See page 112 for our coverage of medications recommended under the Affordable Care Act and page 117 for smoking and tobacco cessation medications.
- Medical foods administered orally are not covered if not obtained at a retail pharmacy or through the Mail Service Prescription Drug Program
Note: See Section 5(a), page 58 for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube.
- Products and foods other than liquid formulas or powders mixed to become formulas; foods and formulas readily available in a retail environment and marketed for persons without medical conditions; low-protein modified foods (e.g., pastas, breads, rice, sauces and baking mixes); nutritional supplements, energy products; and similar items
Note: See Section 5(a), page 58 for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube.
- Infant formula other than described on pages 58 and 109
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Covered Medications and Supplies - continued on next page