Prescription Coverage - Exclusions

Quick Links:
» About Exclusions
» Excluded Medications

Other Prescription Management Controls:
» Prior Authorizations: Click Here
» Exclusions: Click Here
» Quantity & Age Limitations: Click Here
» Specialty Medications: Click Here
» Step Therapies: Click Here
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About Exclusions

In addition to the “Medical and Prescription Drug Exclusions and Limitations” section of the Health Plan's Benefit Book, certain special exclusions apply to prescription drug coverage.
Benefit Book: Click Here

Remember: Just because a medication is Excluded under the Health Plan, it does not mean you cannot fill the prescription. It just means that the Health Plan will not provide any assistance in meeting the cost of the prescription. A listing of medications Excluded are listed below:

Disclaimer: The Health Plan reserves the right to add or remove medications from this list at any time, so please contact the Health Plan Administration office to verify whether a covered medication is subject to a Clinical Prior Authorization (CPA).
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Excluded Medications

Additional Excluded Drugs from Pharmacy Network
» Excluded Drugs List: Click Here

Acthar Gel
» Except for infantile spasms for children aged 2 and under

Alcohol Swabs

Topical Androgens (Testosterone)
» Such as Axiron

Antidepressant Drug - Pristiq

Anti-Fungal Nail Polishes
» Such as Penlac

Anti-Hemophiliac Drugs

Bulk Chemical Powders
» Such as Fentanyl, Gabapentin, Ketamine & Baclofen

Compounded Pain Kits

Cosmetic Agents
» Such as hair growth, hair reduction, facial wrinkle agents such as Botox, bleaching agents, melanin stimulating agents, etc.

Dental Products
» Such as fluorides, gels and pastes except those fluorides covered under Patient Protection & Affordable Care Act

Electrolyte Replacement

Erectile Dysfunction / Impotence Agents
» In ALL forms, such as Viagra & Caverject

Experimental / Investigational Drugs

Gaucher's Disease Medications

Infertility Agents (Oral or Injectable)

Insulin Pumps
» Covered under medical

Juxtapid

Kuvan

E-Cigarettes, Nasal Sprays or Inhalers used for Tobacco Cessation

Male Condoms

Non-Sedating Antihistamines (Brand Names Only)
» Such as Clarinex & Xyzal

Over-The-Counter (OTC) Medications - Except those specifically covered

Passive Immunizing Agents
» Such as Gammagard & Gamunex

PCSK9s
» Such as Praluent

Proton Pump Inhibitors (Brand Names Only)
» Such as Nexium & Vimovo

Surgical Supplies, Medical Devices, Ostomy Supplies, Band-Aids, Splints, Wraps & Hosiery

Weight Loss Medications

Zohydro

Disclaimer: The Health Plan reserves the right to add or remove medications from this list at any time, so please contact the Health Plan Administration office to verify whether a covered medication is subject to a Clinical Prior Authorization (CPA).
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