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Active Health Summary Plan Description
As of July 1, 2022
En Español (PDF)

Article 6: Comparison of Blue Shield PPO Plan, Kaiser HMO and UnitedHealthcare >>

6.4 Limitations and Exclusions

This summary of your Prescription benefits - Limitations and Exclusions affecting your prescription benefits is not intended to take place of the respective medical provider’s (Blue Shield PPO Plan, Kaiser Permanente HMO or UnitedHealthcare HMO) Evidence of Coverage document, Schedule of Benefits or Summary of Benefits and Coverage (SBC). The Evidence of Coverage and Disclosure Document is the legal document that describes the benefits, exclusions and limitations and other coverage provisions including claims appeals, claims review and adjudication procedures.

Please refer to your Evidence of Coverage and Disclosure Document for a complete description of your prescription benefits, including the exclusions and limitations. In the event of any conflict between the information summarized in this section and the provider’s Evidence of Coverage or Schedule of Benefits, the provider’s Evidence of Coverage or Schedule of Benefits shall govern.

Limitation/Exclusion Blue Shield PPO Plan Kaiser Permanente HMO UnitedHealthcare HMO
Drugs for sexual dysfunction for both males and females. Limited to a maximum of eight (8) pills for a 30-day supply and the co-payment will be the same as any other drug. Limited to a maximum of eight (8) doses in any 30-day period or up to 27 doses in any 100-day period.  Standard limitation is maximum of six (6) pills per 30 day supply.
Smoking deterrents when prescribed in writing by a physician. The cost share is $0 cost when prescribed by a provider. No Prior Authorization is required, Must be age 18 or older, bypass deductible. The cost share is $0 for tobacco cessation over-the-counter (OTC) products and outpatient drugs, when ordered as preventive by a Plan provider, in accord with the drug formulary guidelines and obtained from a Plan pharmacy or through mail order service, up to the prescribed amount. The cost share is $0 cost when prescribed by a provider even if OTC. No Prior Authorization is required, Must be age 18 or older, bypass deductible.
Morning after pills and kits Limited to two (2) total per person per 365 days Covered at $0 when prescribed by a Plan provider, in accord with the drug formulary guidelines and obtained from a Plan pharmacy. Coverage for the following products at $0 cost share, bypass deductible. No limits: Aftera, EContra EZ, EContra One Step, Levonorgestrel 1.5 mg, My Choice, My Way, New Day, Opcicon One-Step, Option 2, Preventeza, React, Take Action (generic Plan B One-Step), ella, Plan B One-Step
Prescriptions Drugs for which no charges are made/Workers’ Compensation or other reimbursement programs. Participants will be expected to complete and submit to Anthem Blue Cross all such authorizations, consents, releases, assignments and other documents that may be needed in order to obtain or assure reimbursement under Medicare, Workers€™ Compensation or any other governmental program. If you fail to cooperate, you will be responsible for any charge for services. Drugs for which no charges are made, or which are provided under any Workers’ Compensation or similar benefit or for which reimbursement is provided by any federal, state, or other governmental agency. Drugs for which no charges are made, or which are provided under any Workers’ Compensation or similar benefit or for which reimbursement is provided by any federal, state, or other governmental agency.
Medications available without a prescription (over-the-counter) or prescription medications for which there is a non-prescription equivalent available, even if ordered by a physician via a prescription, except as listed under Covered Drugs. Excluded. This exclusion does not apply to:
a. insulin
b. over-the-counter drugs covered under “Preventive Services” in this “Benefits” section (this includes tobacco cessation drugs and contraceptive drugs).
c. an entire class of prescription drugs when one drug within that class becomes available over-the-counter.		 Excluded.
Infertility drugs. Excluded. Excluded. Covered as part of the medical benefits.
Anorexiants/appetite suppression weight loss drugs. Covered as part of the medical benefits. Weight loss aids are excluded under "Oral nutrition". Not covered, unless required for morbid obesity.
Medications to be taken or administered to the eligible member while he is a patient in a hospital, nursing home (skilled nursing care only), rest home, sanitarium, etc. Covered as part of the medical benefits. Covered as part of the medical benefits. Excluded.
Medications used for cosmetic purposes (For example: Renova, Rogaine, Vaniqa, Penlac, Pigmenting and Depigmenting agents). Excluded. Excluded. Excluded.
Medical devices, therapeutic devices or appliances including hypodermic needle syringes, (except insulin syringes) support garments and other non-medicinal substances. Covered as part of the medical benefits. Covered as part of the medical benefits. Covered as part of the medical benefits.
Drugs or medicines purchased and received prior to the member’s effective date or subsequent to the member’s termination. Excluded. Excluded. Excluded.
Medications prescribed for experimental or non-FDA approved indications unless prescribed in a manner consistent with a specific indication in Drug Information for the Health Care Professional, published by the United States Pharmacopoeial Convention, or in the American Hospital Formulary Services edition of Drug Information; medications limited to investigational use by law. Excluded. Excluded. Excluded.
Homeopathic medications Excluded. Excluded. Excluded.
Unit dose drugs (unless only available as unit dose). Excluded. Excluded under Outpatient prescription drugs, supplies, and supplements exclusion(s). Excluded.
Vitamins (other than prescription prenatal vitamins). Excluded. Excluded. Excluded; except for Prenatal vitamins, vitamins with flouride and single entity vitamins requiring a prescription are covered.
Dental related products (prescription oral and topical fluoride, Peridex, Atridox, Periostat). Excluded. Health Plan covers items prescribed by the following Non–Plan Providers in accord with the drug formulary guidelines and obtained from a Plan pharmacy up to the prescribed amount:
Dentists, if the drug is for dental care.
Drug Intelligence & Strategy
Sodium fluoride dental solution, gel, and cream; chlorhexidine (generic Peridex); doxycycline hyclate (generic Periostat) are on the KP Drug Formulary		 Excluded.
Drug claims submitted after 15 months of the date the drug was dispensed. Excluded. If you have received Services from a Non–Plan Provider that we did not authorize (other than Emergency Services, Post-Stabilization Care, Out-of-Area Urgent Care, or emergency ambulance Services), then as soon as possible after you receive the Services, you must file your claim. Please contact Kaiser Permanente. Excluded.
Biological sera. Excluded. If biological sera is a drug or product requiring administration or observation by medical personnel, deemed medically necessary by a Plan provider in accord with our drug formulary guidelines and administered in a Plan Facility, then Health Plan would cover it under the administered drugs and products benefit. Excluded.
Blood and Blood plasma. Excluded. Covered as part of the medical benefits. Covered as part of the medical benefits, based on medical necessity.
 

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