Injectables. Xylocaine 1% x 2 vials Xylocaine 1% Rid x 1 vial Celeston Solution x 1½ vials Kenalog 40mg x 1 vial Depo Medral 40 Mg x 2 vials Rocephin 1 gram x 2 vials Rocephin 500mg x 2 vials Rocephin 250mg x 5 vials Vistaril 50mg x 1 vial Depo Provera 150mg x 3 vials Benadryl 50 mg. x 1 vial Depo Testosterone 200 mg. x 3½ vials Delestrogen x 2½ vials B12 x 2½ vials B Complex x 2 vials Compazine 5mg X 1 vial Bacteriostat Water x 1 vial Sodium Chloride 0.9% Nitrostat Hepatitis B Vaccine x 3 injectables Hepatitis A Vaccine x 2 injectables Yellowfever x 2 vials Meningococcal Vaccine x 2 vials Thyphoid x 3 injectables Poliovirus Vaccine x 1 vial Tetanus Tyoid x 1 vial Tetanus Dip. x 5 vials MMR x 2 injectables Rubella Vaccine x 1 vial
Injectables d. All of the above
Injectables. Drugs other than oral medications (as indicated in HCPCS book for codes J0001-J8999 and Q codes or any replacement codes or any NDC equivalent codes) for non-chemotherapy medications, excluding clotting factors (J7190-J7199) and Blood Products.
Injectables. Unless specifically excluded, and when an oral alternative drug is not available, injectable medication is a covered benefit, including those medications intended to be self administered. Medications must be deemed medically necessary and appropriate to the Member's needs or condition for covered services, prescribed by a participating provider and approved in advance of treatment by HMO. If the drug therapy treatment is approved for self-administration, Member is required to obtain covered medications at a U.S. Healthcare participating pharmacy designated to fill injectable prescriptions. Experimental or investigational drugs or medications or drugs or medications that have not been proven safe and effective for a specific disease or approved for a mode of treatment by the FDA and the NIH are not covered under this contract. The off-label use of injectable drugs or medications is not covered. Drugs related to the treatment of noncovered services are not covered. Drugs related to the treatment of infertility, contraception and performance enhancing steroids are not covered. Needles, syringes and other injectable aids are not covered.
Injectables. Injectables obtained from Non-Preferred Providers are not covered.
Injectables. Off label use, unless approved by Us or the PBM or when the drug has been recognized as safe and effective for treatment of that indication in one or more of the standard medical reference compendia adopted by the United States Department of Health and Human Services or in medical literature that meets certain criteria. Medical literature may be accepted only if all of the following apply: (1) Two articles from major peer-reviewed professional medical journals have recognized the drug’s safety and effectiveness for treatment of the indication for which it has been prescribed; (2) No article from a major peer-reviewed professional medical journal has concluded that the drug is unsafe or ineffective or that the drug’s safety and effectiveness cannot be determined for the treatment of the indication for which it has been prescribed; (3) Each article meets the uniform requirements for manuscripts submitted to biomedical journals established by the international committee of medical journal editors or is published in a journal specified by the United States Department of Health and Human Services as acceptable peer-reviewed medical literature. Non covered Prescription Drug Benefits include: • Prescription Drugs dispensed by any Mail Service program other than Our Pharmacy Benefit Manager’s Mail Service, unless prohibited by law. • Drugs, devices and products, or Prescription Legend Drugs with over the counter equivalents and any Drugs, devices or products that are therapeutically comparable to an over the counter Drug, device, or product. This Exclusion does not apply to over-the-counter products that We must cover under federal law with a Prescription. • Drugs in quantities exceeding the quantity prescribed, or for any refill dispensed later than one year after the date of the original Prescription Order. • Drugs not approved by the FDA. • Charges for the administration of any Drug. • Drugs consumed at the time and place where dispensed or where the Prescription Order is issued, including but not limited to samples provided by a Physician. This does not apply to Drugs used in conjunction with a Diagnostic Service, with Chemotherapy performed in the office or Drugs eligible for coverage under the Medical Supplies benefit; they are Covered Services. • Any Drug which is primarily for weight loss. • Drugs not requiring a prescription by federal law (including Drugs requiring a prescription by state law, but not by federal law), except for injectable insulin. • Dru...
