Not Covered

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

Benefits Description

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
Drugs used in conjunction with IVF that exceed the covered 3 per year annual cycle limitation described in this section
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 or you are enrolled in the FEP Medicare Prescription Drug Program (see Section 5(a))
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 previous benefits in this section for our coverage of medications recommended under the Affordable Care Act and 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) 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) for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube.
Infant formula other than described in this section and in Section 5(a)
Drugs for which prior approval has been denied or not obtained
Drugs and supplies related to sexual dysfunction or sexual inadequacy
Drugs and covered-drug-related supplies for the treatment of gender dysphoria if not obtained from a retail pharmacy or through the Mail Service Prescription Drug Program or Specialty Drug Pharmacy Program as previously described in this section
Drugs purchased through the mail or internet from pharmacies outside the United States by members located in the United States
Over-the-counter (OTC) contraceptive drugs and devices, except as previously described in this section
Drugs used to terminate pregnancy
Sublingual allergy desensitization drugs, except as described in Section 5(a)

Standard Option - You Pay
All charges

Basic Option - You Pay
All charges