Active Health Summary Plan Description
As of September 1, 2017
En Español (PDF)
The Mandatory Generic Prescription Drug Plan covers the following services and materials:
- Federal Legend Drugs: Any medicinal substance which bears the legend, "Caution: Federal law prohibits dispensing without a prescription."
- State Restricted Drugs: Any medicinal substance, which may be dispensed by prescription only according to state law.
- Federal legend Oral Contraceptives/Birth control pills
- Contraceptive products, including, but not limited to Diaphragms, Cervical Caps, Depo-Provera Injection and Ortho-Evra Patches.
- Inhaler extender devices and bags (Aerochamber™, Aerochamber™, w/ mask, Easivent™, Inspirsease™, EZ-Spacer™, Optichamber™, Optihaler™, Ellipse, etc.) are part of the pharmacy benefit.
- 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™.
- Compounds with at least one federal legend or state restricted ingredient
- Normal saline for inhalation and irrigation
- Prescription prenatal vitamins
- 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:
- Insulin, insulin syringes and needles
- Blood glucose test strips
- Urine glucose test strips
- Sterile lancets
- Novolin Pen, Humulin Pen, Prefilled pens, Pen needles; cartridges