Expenses That Are Not Covered

The Plan does not cover certain expenses, including (but not limited to) the following:

  • Items lawfully obtainable without a prescription, except for those items specifically listed in "Covered Expenses"
  • Devices and appliances
  • Prescription drugs covered without charge under federal, state, or local programs, including workers' compensation
  • Costs covered by manufacturer coupons used to purchase the prescription drugs
  • Drugs used for cosmetic reasons
  • Any charge for the administration of a drug or insulin
  • Experimental or investigational drugs
  • Any drug that is not medically necessary
  • Unauthorized refills
  • Immunization agents, biological sera, blood, or plasma
  • Drugs for an eligible person confined to a rest home, nursing home, sanitarium, extended care facility, hospital, or similar entity
  • Any charge above the usual and customary, advertised, or post price, whichever is less than the scheduled amount
  • Anabolic steroids
  • Testosterone, except in the case of a diagnosis of hypogonadism, in which case testosterone is covered if your physician provides a letter of medical necessity
  • Fertility drugs
  • Drugs that are not FDA-approved (with FDA-approved labeling) based on the patient's history and/or current diagnosis
  • Expenses that would have been paid by a plan that was available from the spouse’s employer, regardless of whether the plan was elected by the spouse
  • Drugs that the Plan determines are not eligible based on therapeutic or market conditions
  • Non-approved diabetic products (see products noted as “Excluded” in the Coverage Tiers (Formulary)
  • Specific overly expensive drugs with clinically effective alternatives (see drugs noted as “Excluded” in the Coverage Tiers (Formulary)
  • Certain prescription drugs if “step therapy” is not tried first (see drugs noted with “Step Therapy” in the Coverage Tiers (Formulary)
  • Compound drugs (custom-made) if not provided by EnvisionCompounding
  • Specialty drugs if not provided by EnvisionSpecialty or Thrifty Pharmacy, unless the drug is a prior-authorized limited distribution drug (LDD)
  • Any drugs beyond the quantity limit specified by Envision/Rx; see products noted with “QL” in the Coverage Tiers (Formulary), and contact Envision at (800) 361-4542 for information about specific limits for any given drug
  • Narcotic-Addiction Drugs beyond the six-month lifetime cap
  • Any drugs obtained without the required prior authorization; see drugs noted with “Requires PA” in the Coverage Tiers (Formulary)
  • Any expense listed in "Expenses That Are Not Eligible" in the Medical Plan section, except for those specifically covered by the Plan

In the event of Care Coordination non-compliance (when required for your condition), a penalty equal to 40% of the amount the Plan would normally pay will be applied to expenses related to the condition, including prescription drug expenses. See "Care Coordination" in the Medical Plan section.