Pharmacy Benefits — Covered Drugs
Prior Authorization
Your prescription drug program provides coverage for some drugs only if
prescribed for certain uses, durations, and/or quantities. For this reason, some
prescriptions must receive prior authorization before they can be covered under
your benefit. Either your pharmacist may initiate the review process or you may
be asked to request that your doctor initiate the review. It may be required at
times for Medco Health to contact your doctor to get necessary information to
determine coverage eligibility. Following the review process, both the member
and the physician will be notified as to the results of the review process. If
your prescription is found not to be covered, you will be required to pay the
full price of the prescription. An appeals process is available in the case of
coverage denial.
What Drugs Are Covered?
- Legend Drugs (federal law requires these drugs be dispensed by
prescription only)
- Compounded drugs containing at least one legend ingredient
- Insulin
- Disposable insulin syringes/needles
- Blood glucose testing strips/supplies, glucometers
- Legend contraceptives; injectable contraceptives
- Any other drug which, under applicable state law, may
only be dispensed upon the written prescription of a physician or other lawful
prescriber
- Growth hormone (limited to patients under age 18 with pituitary
dwarfism or Turner's syndrome and approved by Medco Health)
- Retin A ® (through age 35, over age 35 with approval
through prior authorization)
What Drugs Are Not Covered?
- Anorexiants (drugs for weight reduction) lonamin ®,
Pondimin ®, Redux ®, Meridia ®, etc.
- Non-legend drugs other than those listed above
- Viagra ®, Muse ®, Cavereject ®, Levitra, and others
for erectile dysfunction
- Renova ®
- Rogaine®, Propecia ® (or similar products whose sole
purpose is to stimulate or promote hair growth)
- Drugs labeled "Caution-limited by federal law to
investigational use," or experimental drugs
- Infertility drugs unless authorized by a provider in
the Duke Division of Reproductive Endocrinology
- Drugs which are purchased outside of the United
States and do not have FDA approval
- Immunization agents, biological sera, blood or blood
plasma or products derived from blood or blood products
- Medical devices and applications (except glucometers
prescribed by your physician)
- Charges for the administration/injection or
compounding of any drug that are in addition to negotiated fees
- Over-the-counter items
- Take-home drugs from an inpatient facility
- Replacement of drugs that have been lost, stolen or
destroyed
- Drugs prescribed by provider for himself/herself or
hsi/her immediate family
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