Document Number:
SB24-118
Revision #:
v1.1
Date Published:
3/18/2024
2024 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
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- 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 previously 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
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Covered Medications and Supplies - continued on next page