2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f). Prescription Drug Benefits
Page 94
Section 5(f). Prescription Drug Benefits
Page 94
Benefits Description
Covered Medications and Supplies (cont.)
Tier 1 and 2 drugs purchased from a Preferred pharmacy include, but are not limited to the following:
You Pay
See pages 93 and 97
Covered Medications and Supplies (cont.)
Tier 1 and 2 drugs purchased from a Preferred pharmacy include, but are not limited to the following:
- Drugs, vitamins and minerals, and nutritional supplements included in our closed formulary that by Federal law of the United States require a prescription for their purchase
Note: See page 96 for our coverage of medications to promote better health as recommended under the Affordable Care Act.
- Medical foods, as defined by the U.S. Food and Drug Administration, that are consumed or administered enterally and are intended for the specific dietary management of a disease or condition for which there are distinctive nutritional requirements.
The Plan covers medical food formulas and enteral nutrition products that are ordered by a healthcare provider, and are medically necessary to prevent clinical deterioration in members at nutritional risk. (See Coverage below)
- Must meet the definition of medical food (see definition on page 131)
- Must be receiving active, regular, and ongoing medical supervision and must be unable to manage the condition by modification of diet alone
- Must meet the definition of medical food (see definition on page 131)
Coverage is provided as follows:
- Inborn errors of amino acid metabolism
- Food allergy with atopic dermatitis, gastrointestinal symptoms, IgE mediation, malabsorption disorder, seizure disorder, failure to thrive, or prematurity, when administered orally and is the sole source (100%) of nutrition. This once per lifetime benefit is limited to one year following the date of the initial prescription or physician order for the medical food (e.g., Neocate, in a formula form or powders mixed to become formulas)
- Medical foods and nutritional supplements when administered by catheter or nasogastric tubes
Notes:
- A prescription and prior approval are required for medical foods provided under the pharmacy benefit. Renewals of the prior authorization are required every benefit year for inborn errors of metabolism and tube feeding.
- See Section 5(a), page 54, for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube under the medical benefit.
- Insulin, diabetic test strips, lancets and tubeless insulin delivery systems
Note: See page 53 for our coverage of insulin pumps with tubes.
- Needles and disposable syringes for the administration of covered medications
- Clotting factors and anti-inhibitor complexes for the treatment of hemophilia
You Pay
See pages 93 and 97
Covered Medications and Supplies - continued on next page