Active Health Summary Plan Description
As of September 1, 2017
En Español (PDF)

8.4 Covered Benefits

The Mandatory Generic Prescription Drug Plan covers the following services and materials:

  1. Federal Legend Drugs: Any medicinal substance which bears the legend, "Caution: Federal law prohibits dispensing without a prescription."
  2. State Restricted Drugs: Any medicinal substance, which may be dispensed by prescription only according to state law.
  3. Federal legend Oral Contraceptives/Birth control pills
  4. Contraceptive products, including, but not limited to Diaphragms, Cervical Caps, Depo-Provera Injection and Ortho-Evra Patches.
  5. Inhaler extender devices and bags (Aerochamber™, Aerochamber™, w/ mask, Easivent™, Inspirsease™, EZ-Spacer™, Optichamber™, Optihaler™, Ellipse, etc.) are part of the pharmacy benefit.
  6. Anaphylaxis prevention kits, including but not limited to Epi-Pen™/Epi-Pen Jr. ™, Ana-Kits™, Ana-Kit Jr. ™, Glucagon, Glucagon Emergency Kit, and Ana-Guard™.
  7. Compounds with at least one federal legend or state restricted ingredient
  8. Normal saline for inhalation and irrigation
  9. Prescription prenatal vitamins
  10. Injectables (see the Exclusions subsection below for exceptions)

The following non-prescription items are also covered when prescribed in writing by a physician and dispensed by a licensed pharmacist:

  1. Insulin, insulin syringes and needles
  2. Blood glucose test strips
  3. Urine glucose test strips
  4. Sterile lancets
  5. Novolin Pen, Humulin Pen, Prefilled pens, Pen needles; cartridges