Active Health Summary Plan Description
As of September 1, 2017
En Español (PDF)
The following items are not covered:
- If enrolled in an HMO (Kaiser or UnitedHealthcare), all injectables, except insulin, which are included as part of your medical benefit to be administered in a doctor's office, and are an exclusion, Citizens Rx, and out-of-network plans.
- Drugs for which no charges are made, or which are provided under any Workers' Compensation or similar benefit or for which reimbursement is provided by any federal, state, or other governmental agency.
- Medications available without a prescription (over-the-counter) or prescription medications for which there is a non-prescription equivalent available, even if ordered by a physician via a prescription, except as listed under Covered Drugs
- Infertility drugs.
- Anorexiants/appetite suppression weight loss drugs.
- Medications to be taken or administered to the eligible member while he is a patient in a hospital, nursing home (skilled nursing care only), rest home, sanitarium, etc.
- Medications used for cosmetic purposes (For example: Renova, Rogaine, Vaniqa, Penlac, Pigmenting and Depigmenting agents).
- Medical devices, therapeutic devices or appliances including hypodermic needle syringes, (except insulin syringes) support garments and other non-medicinal substances (unless listed as covered).
- Drugs or medicines purchased and received prior to the member's effective date or subsequent to the member's termination.
- Drugs or medicines purchased or administered to the participant by a prescriber or prescriber's staff. For example, drugs administered, injected or dispensed by a physician. However, injectables obtained at a pharmacy shall be covered.
- Medications prescribed for experimental or non-FDA approved indications unless prescribed in a manner consistent with a specific indication in Drug Information for the Health Care Professional, published by the United States Pharmacopoeial Convention, or in the American Hospital Formulary Services edition of Drug Information; medications limited to investigational use by law.
- All homeopathic medications.
- Unit dose drugs (unless only available as unit dose).
- Vitamins (other than prescription prenatal vitamins).
- Dental related products (prescription oral and topical fluoride, Peridex, Atridox, Periostat).
- Drug claims submitted after 15 months of the date the drug was dispensed.
- Biological sera.
- Blood and Blood plasma.