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IHC Prescription Drugs Excluded


The following types of drugs and medications are excluded or limited:
  • Appetite suppressants and weight loss medications.
  • Cosmetics, health or beauty aids or prescription drugs used for cosmetic purposes including tretinoin (Retin-A®) for non-acne therapy.
  • DDAVP (Desmopressin Acetate®) is only covered if preauthorized. DDAVP will be covered for treatment of enuresis for a period not to exceed six months and only if preauthorized at three month intervals.
  • DMSO (dimethyl sulfoxide) is only covered if preauthorized.
  • Drug use that is not medically necessary.
  • Employment-required drugs and injections except for Hepatitis A.
  • Experimental drugs, medications labeled "Caution: Limited by Federal Law to Investigational Use," drugs not approved by the FDA, or FDA-approved drugs used for treatment not recognized by the Plan (Refer to your employer's Master Group Contract for a complete definition of 'experimental and/or investigational').
  • Food supplements, food substitutes, medical foods, and formulas (except when related to treatment of inborn errors of amino acids or urea cycle metabolism).
  • Human growth hormone, except when preauthorized in writing by the Plan's Medical Director as being medically necessary.
  • Infertility medications.
  • Minerals, fluoride, vitamins other than prenatal. Vitamins are covered only when determined to be medically necessary to treat a specifically diagnosed disease.
  • Nicotine and smoking cessation medications. Exception: these may be covered depending upon the member's particular prescription drug benefits and participation in a Plan-sponsored smoking cessation program.
  • Non-covered medical condition medications, (e.g., topical minoxidil, Nystatin® powder, etc.).
  • Norplant® - Limited coverage is provided for Norplant insertion and removal. The member pays a $150 copayment for Norplant insertion. The $150 copayment will be required regardless of your plan's coinsurance and copayment requirements for other services. Norplant removal is covered only after five years from when the insertion date has transpired, or if earlier removal is medically necessary. For Norplant removal, office surgery benefits apply (Refer to your Member Payment Summary for specific Office Surgery benefits). To be eligible for preferred benefits, Norplant services must be rendered by a participating provider.
  • Over-the-counter medication (OTC).
  • Prescriptions received under workers' compensation or reimbursable under local, state, or federal programs or other insurance plans.
  • Prescriptions written by a licensed dentist, unless for the prevention of infection or pain in conjunction with a dental procedure.
  • Progesterone suppositories, except when used in pregnancy or other FDA-approved use.
  • Sexual dysfunction medications, including but not limited to, alprostadil (Caverjet®, Muse®, Edex®), yohimbine (Yocon®), sildenafil (Viagra®), unless the Sexual Dysfunction Rider is listed as a Benefit Rider on the Member Payment Summary.
  • Travel-related preventive drugs and injections, except for Hepatitis A. Preventive benefits normally cover one routine exam per year along with the related tests and covered immunizations as long as the services are not employment or travel-related.
  • Vitamin Injections - Vitamin injections are covered only when determined by the Plan to be medically necessary for members with specifically diagnosed diseases where oral vitamins cannot be absorbed by the body's gastrointestinal system.
  • For covered injectable drugs see the "Injections and Immunizations" section of your member materials.
The following drugs are not covered:

A.P.L. (fertility)

Adagen

Adipex

Aldera

Aminaide

Amvisc

Attaine

Cerezyme

Chorex(5 or 10)

Chorionic Gondaotropin

Clomid (fertility)

Clomiphene

Enfamil

Enrich

Ensure

Ensure Plus

Fastin

Fertinex

Flumadine

Fluoride Preparations

Follistim

Gonal/NF

Habitrol

Healon

Healon GV

Healon Yellow

Hepatide

Humagon

Ionamin

Isocal

Jevity

Lariam

Lotronox

Lutrepulse

Malarone

Metrodin (fertility)

Microlipids

Milophene

Multivitamins

Nicorette

Nicotrol

Osmolyte

Pediatric

Pergonal

Plan B

Pregestinil

Pregnyl (fertility)

Profasi (fertility)

         Propecia

Prosobee

Prostep

Provisc

Pulmocare

Relenza

Renova

Repronex

Rogaine

RU486

Serophene (fertility)

Similac

Tamiflu

Vaniqa

Viscoat

Vitrax

Vivonex

Vivotif

Xenical

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