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Summary Plan Description (SPD)
Limitations:
Please note: copay amounts have changed, effective 10/1/2006. Please see Amendment 5 for more information.
This section modified by: Amendment 11. View Previous Language
The following items are a covered benefit subject to the limitations as stated below:
- Drugs to treat erectile dysfunction (including but not limited to Viagra, Cialis and Levitra) – coverage will be for prescriptions limited to a maximum of eight (8) pills for a 30-day supply for males (excluded for females). The participant will be responsible for a copayment equal to fifty percent (50%) of the total retail cost of the prescription.
- Smoking deterrents when prescribed in writing, by a physician, subject to the following limitations: up to 90 days supply per year; lifetime maximum benefit, 180 days supply. This limitation applies to smoking deterrents received from both retail and mail pharmacy outlets. It is recommended you discuss a treatment plan with your physician. There are many products to assist you in smoking Cessation. These include the following:
- Nicotine Patches
- Nicotine Gum
- Nicotine Nasal Spray (Rx Required)
- Nicotine Inhalers (Rx Required)
- Nicotine Lozenges
- Zyban (Bupropion) (Rx Required)
- Morning after pills & kits (i.e., Preven, Plan B)- (limited to 2 total per person per 365 days)
Exclusions:
The following items are not covered:
- If enrolled in PacifiCare, all injectables, except insulin, which are included as part of your medical benefit to be administered in a doctor's office are an exclusion.
- Any pharmaceutical services provided under any other sections of the Indemnity portion of the Plan and described in this Summary Plan Description.
- Drugs for which no charges are made, of 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
- Infertility drugs.
- Anorexiants/appetite suppression weight loss drugs.
- Medications for the treatment of sexual dysfunction (except Viagra, Cialis and Levitra).
- 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.
- Medications used for cosmetic purposes (For example: Renova, Rogaine, Vaniqa, Penlac, Pigmenting & Depigmenting agents).
- Medical devices, therapeutic devices or appliances including hypodermic needle syringes, (except insulin syringes) support garments and other non-medicinal substances (unless listed as covered).
- Drugs or medicines purchased and received prior to the member’s effective date or subsequent to the member’s termination.
- Drugs or medicines delivered or administered to the member by a prescriber or prescriber’s staff. For example, drugs administered, injected, or dispensed by a physician.
- 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.
- All homeopathic medications.
- Unit dose drugs (unless only available as unit dose).
- Vitamins (other than prescription prenatal vitamins).
- Dental related products (prescription oral and topical fluoride, Peridex, Atridox, Periostat).
- Biological sera.
- Blood and Blood plasma.