Summary Plan Description

Limitations and Exclusions

Benefits are not provided for:

  1. Prescription or nonprescription vitamins, cosmetics, or nutritional supplements.
  2. Drugs or medications furnished by a physician or dentist, or drugs dispensed during an inpatient admission by a hospital, skilled nursing facility, sanatorium, or other facility.
  3. Over-the-counter (nonlegend) drugs, meaning drugs for which a physician's prescription is not required by law, except as mandated by the Affordable Care Act (ACA) or provided under Tobacco Management.
  4. Fertility drugs.
  5. Prescriptions used to treat impotence, except as provided under Erectile Dysfunction.
  6. Weight reduction drugs.
  7. Infusion therapy, except as provided under Infusion Therapy.
  8. Fluoride and other dental-related medications.
  9. Smoking deterrents, except as mandated by the Affordable Care Act (ACA) or provided under Tobacco Management.
  10. Delivery or handling charges.
  11. Prescriptions filled in excess of the number prescribed by the physician, prescription drugs prescribed either by someone who is not allowed by the state to prescribe such prescription drugs or by a provider who is not covered under this plan, or any refill after one year from the date of the physician's order.
  12. Appliances, devices and other nondrug items including, but not limited to, therapeutic devices and artificial appliances, except as provided under Medical Supplies or Prosthetic Devices and Artificial Limbs.
  13. Experimental or investigative drugs including compound medications for non-FDA approved use.
  14. Drugs that are not medically necessary or clinically proven for the treatment of an illness, injury or other covered condition.
  15. Drugs or medications for which reimbursement is provided by any federal government, state, county, municipality, or special district, or Medicare.
  16. Biologicals, blood, or blood plasma, except as provided under Blood.
  17. Drugs for cosmetic purposes.
  18. Antigen and allergy vaccines or serums, except as provided under Physician Services.
  19. Immunizing agents, except as mandated by the Affordable Care Act (ACA) for recommended preventive care benefits.