Benefits are not payable under Prescription Drug Benefits for:
- Medicines or drugs obtainable without a Physician’s prescription, except insulin,
- All forms of contraceptives, including medicines and devices, unless they are Medically Necessary,
- Medications used for cosmetic purposes, including Vitamin A derivatives (retinoids) for dermatological use (i.e. Retin A, Renova),
- Vitamins and nutritional supplements,
- Smoking deterrents (except as provided under the Wellness Benefit),
- Fertility drugs (except as provided under the Infertility Benefit),
- Viagra and other erectile dysfunction drugs. However, Prescription Drugs prescribed by the treating Physician to treat erectile dysfunction will be covered if:
- You have or had one of the following: Prostate and testicular cancer, disorders of the prostate (including prostatic enlargement and hyperplasia), low testosterone level, Diabetes, Crohn’s disease, Peripheral neuropathy, Hypertension and other vascular conditions, or erectile dysfunction as a side effect from another prescription medication or combination of medications that can be verified as a side effect, which is listed in the Physician’s Desk Reference; and
- You provide the following information: A letter of Medical Necessity from your attending Physician, complete diagnosis, and name and dosage of medication prescribed.
Re-verification from the Physician is required every twelve-month period.
- Anabolic steroids,
- Antiviral drugs used for influenza (flu) treatment or prevention,
- Weight control or drugs or anorexiants, except those used for treatment of Children with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) or individuals with narcolepsy,
- Serum allergy antigen solutions, and
- Existing and new drugs that are not uniformly and professionally endorsed by the general medical community for prescription in the course of standard medical care, including existing and new drugs that are experimental in nature.