Not Covered

This brochure version is for internal use only.

2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits

Benefits Description
Not covered:

Drugs and supplies purchased from a Non-preferred pharmacy
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 Preferred retail pharmacy or except when Medicare Part B is primary. See pages 53 and 94.
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 96 for our coverage of medications recommended under the Affordable Care Act and page 98 for smoking and tobacco cessation medications.
Medical foods administered orally are not covered if not obtained at a Preferred retail pharmacy

Note: See Section 5(a), page 54, 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), page 54, for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube.
Infant formula other than described on pages 54 and 94
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 described on pages 93 and 98

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 described on page 95
Drugs used to terminate pregnancy
Sublingual allergy desensitization drugs, except as described on page 48

You Pay
All charges