Prescription Drugs Covered by the Prescription Drug Plan
|
Drug
|
Coverage Status
|
|
Allergy Serums (oral immunotherapy drugs)
|
Covered but requires prior authorization
|
|
Aspirin
|
Covered — generic aspirin (81mg only) is fully covered without a deductible as prevention medication
1) after 12 weeks of gestation in women who are at high risk for preeclampsia (Age limit: 12 or older, quantity limit: 100 units per fill);
2) for primary prevention of cardiovascular disease and colorectal cancer (Age limit: 50 to 59 years, quantity limit: 100 units per fill)
OTC products require prescription
|
|
Breast Cancer Drugs
|
Covered — generic anastrozole, exemestane, raloxifene, and tamoxifen are fully covered without a deductible as part of a treatment therapy for women at risk for breast cancer and/or diagnosed with breast cancer for age 35 or older
|
|
Contraceptives
|
Covered — generic prescription contraceptives are fully covered without a deductible, as are brand-name prescription contraceptives for which a generic is not available, such as Lo Loestrin® 24 Fe.
Please Note: If a generic prescription becomes available for a brand-name contraceptive, the generic form of the contraceptive will be fully covered without a deductible, while the brand-name version of the contraceptive would be covered according to the provisions for other brand-name medications (see chart under "How Prescription Drug Benefits Are Paid Under the Medical Plan").
|
|
Diabetic Supplies (includes certain glucose monitors, insulin pumps and related pump supplies)*
|
Covered - except alcohol wipes
|
|
Diet Medications (anorexiants and anti-obesity)
|
Covered but requires prior authorization
|
|
Fluoride Supplements
|
Covered — generic fluoride supplements are fully covered without a deductible for children age 5 or younger
|
|
Infertility Drugs (exclusive of treatment)
|
Covered up to a $10,000 lifetime maximum (combined Retail Pharmacy Benefit and Maintenance Choice® program) per person
|
|
Legend Vitamins
|
Covered
|
|
Male Impotency Drugs
|
Covered at 8 units per 30 days (24 units per 90 days through Maintenance Choice®).
|
|
Prescription Tobacco Cessation Products
|
Covered
|
|
Proton Pump Inhibitors (PPIs) (such as Prilosec, Tagamet, and Nexium)
|
Covered subject to preauthorization, as described under "Coverage for Proton Pump Inhibitors"
|
|
Respiratory Therapy Supplies
|
Covered — except nebulizers.
|
|
Solaraze (Diclofenac sodium gel 3%)
|
Covered but requires prior authorization.
|
|
Solodyn
|
Covered but requires prior authorization.
|
* Some glucose monitors and insulin pumps are available under the Medical Plan. For information on which insulin pumps are covered under the Medical and/or Prescription Drug Plan, please contact the appropriate provider (Aetna/Cigna and/or CVS Caremark)