Expenses That Are Not Eligible
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 "Eligible 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
- 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” (EX) in the Covered Medication Search
- Specific overly expensive drugs with clinically effective alternatives (see drugs noted as “Excluded” (EX) in the Covered Medication Search
- Certain prescription drugs if “step therapy” is not tried first (see drugs noted with “Step Therapy” (ST) in the Covered Medication Search
- Specialty drugs if not provided by Elixir Specialty, unless the drug is a prior-authorized limited distribution drug (LDD)
- Any drugs beyond the quantity limit specified by Elixir; see products noted with “Quantity Limit” (QL) in the Covered Medication Search, and contact Elixir at (800) 361-4542 for information about specific limits for any given drug
- Any drugs obtained without the required prior authorization; see drugs noted with “Prior Authorization” (PA) in the Covered Medication Search
- Any expense listed in "Expenses That Are Not Eligible" in the Medical Plan section, except for those specifically listed as covered by the Prescription Drug Plan
If the Plan determines that Care Coordination is required and you decline to utilize or cooperate with Care Coordination, the Plan may impose a benefit penalty equal to 40% of the amount the Plan would normally pay with respect to expenses related to the requirement, including prescription drug expenses. See "Care Coordination" in the Medical Plan section.
