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 expenses related to a claim where the provider or manufacturer did not require the member to pay the required deductibles, copays, coinsurance, and/or benefit penalties in full. The member is required to pay these out-of-pocket expenses under the terms of the Plan. This requirement cannot be waived by a provider or manufacturer under any “fee forgiveness,” “no out-of-pocket,” “coupon,” or similar arrangement. If a provider or manufacturer waives the required out-of-pocket expenses, the covered person’s claim may be denied, or benefits reduced, and the member will be responsible for payment of the remaining balance. The claim(s) may be reconsidered if the member provides satisfactory proof to the Plan Administrator that he or she paid the out-of-pocket expenses under the terms of the Plan.
  • 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.