2026 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(f)(a). FEP Medicare Prescription Drug Program
Page 97

 

Benefits Description

Covered Medications and Supplies (cont.)
 
  • Insulin and diabetic supplies except when obtained from a Preferred retail pharmacy 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 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
     
  • For members enrolled in our regular pharmacy drug program (Section 5(f) only), drugs prescribed in connection with Sex-Trait Modification for treatment of gender dysphoria 
    If you are mid-treatment under this Plan, within a surgical or chemical regimen for Sex-Trait Modification for diagnosed gender dysphoria, for services for which you received coverage under the 2025 Plan brochure, you may seek an exception to continue care for that treatment. If you have questions about the exception process, contact us using the customer service number listed on the back of your ID card. If you disagree with our decision, please see Section 8 of this brochure for the disputed claims process.
    Individuals under age 19 are not eligible for exceptions related to services for ongoing surgical or hormonal treatment for diagnosed gender dysphoria    .
     
  • 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
 
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