2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits
Page 99
Section 5(f). Prescription Drug Benefits
Page 99
Benefits Description
Covered Medications and Supplies (cont.)
Not covered:
You Pay
All charges
Covered Medications and Supplies (cont.)
Not covered:
- Medical foods administered orally are not covered if not obtained at a Preferred retail pharmacy
Note: See Section 5(a) for our coverage of medical foods 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 not listed on the formulary or preferred drug list
- Brand name opioids
- Remicade, Renflexis, and Inflectra are not covered for prescriptions obtained from a Preferred retail pharmacy, or through the Specialty Drug Pharmacy Program
- 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 Preferred retail pharmacy or the Specialty Drug Pharmacy Program as previously described in this section
- Drugs purchased through the mail or internet from pharmacies inside or 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)
You Pay
All charges
Benefits Description
Drugs From Other Sources
Covered prescription drugs and supplies not obtained at a retail pharmacy or through the Specialty Drug Pharmacy Program to include, but not limited to:
You Pay
Preferred professional providers and facilities: 30% of the Plan allowance (deductible applies)
Non-preferred professional providers (Participating/Non-participating) and Non-preferred facilities (Member/Non-member): You pay all charges
Drugs From Other Sources
Covered prescription drugs and supplies not obtained at a retail pharmacy or through the Specialty Drug Pharmacy Program to include, but not limited to:
- Physician’s office – for more information refer to Section 5(a)
- Facility (inpatient or outpatient) – for more information refer to Section 5(c)
- Hospice agency – for more information refer to Section 5(c)
- Drugs obtained at a physician’s office, inpatient or outpatient facility or hospice agency while overseas, see Section 5(i)
- Drugs and supplies covered only under the medical benefit, see auto-immune infusions below
- Prescription drugs obtained from a Preferred retail pharmacy, that are billed by a skilled nursing facility, nursing home, or extended care facility previously described in this section
You Pay
Preferred professional providers and facilities: 30% of the Plan allowance (deductible applies)
Non-preferred professional providers (Participating/Non-participating) and Non-preferred facilities (Member/Non-member): You pay all charges
Drugs From Other Sources - continued on next page