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 (except the Shingles vaccine), 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 his/her immediate family