Covered Prescription Drugs. FDA approved formulary prescription drugs. Federal law requires a prescription for these drugs. They are known as “legend drugs.” • Compound drugs when the main drug ingredient is a covered prescription drug • Oral drugs for controlling blood sugar levels, insulin and insulin pens • Throw-away diabetic test supplies such as test strips, testing agents and lancets • Drugs for shots you give yourself • Needles, syringes and alcohol swabs you use for shots • Glucagon emergency kits • Inhalers, supplies and peak flow meters • Drugs for nicotine dependency. Generic over the counter (OTC) also covered. • Human growth hormone drugs when medically necessary
Covered Prescription Drugs. The prescription drugs covered by this Section V.K.5. are:
Covered Prescription Drugs. FDA approved formulary prescription drugs. Federal law requires a prescription for these drugs. They are known as “legend drugs.” Compound drugs when the main drug ingredient is a covered prescription drug Oral drugs for controlling blood sugar levels, insulin and insulin pens Throw-away diabetic test supplies such as test strips, testing agents and lancets Drugs for shots you give yourself Needles, syringes and alcohol swabs you use for shots Glucagon emergency kits Inhalers, supplies and peak flow meters Drugs for nicotine dependency. Generic over the counter (OTC) also covered. Human growth hormone drugs when medically necessary All FDA approved oral contraceptive drugs and devices such as diaphragms and cervical caps are covered in full when provided by an in-network pharmacy, see Preventive Drugs in the Summary of Your Costs Oral chemotherapy drugs Drugs associated with an emergency medical condition (including drugs from a foreign country)
Covered Prescription Drugs. We cover Medically Necessary Prescription Drugs that, except as specifically provided otherwise, can be dispensed only pursuant to a prescription and are: • Not Experimental/Investigative; • Determined by Us to be appropriate in quantity; • Determined by Us to be appropriate for Your age; • Required by law to bear the legend “Caution – Federal Law prohibits dispensing without a prescription”; • FDA approved; • Ordered by a Provider authorized to prescribe and within the Provider’s scope of practice; • Prescribed within the approved FDA administration and dosing guidelines; and • Dispensed by a licensed, Network Pharmacy. • Covered Prescription Drugs Benefits include but are not limited to the following: • Prescription Legend Drugs • Specialty Drugs • Injectable insulin and syringes used for administration of insulin. • Oral contraceptive Drugs, injectable contraceptive drugs and patches are covered when obtained through an eligible Pharmacy. Certain contraceptives are covered under the “Preventive Care” benefit. Please see that section for further details. • 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:
