Mail Order
Exclusion List Plan approved maintenance medications are available through mail
order if the member’s employer has purchased a mail order benefit.
Maintenance medications are those drugs that are needed for long-term or
chronic conditions such as high blood pressure or diabetes. Some of the drugs
that are excluded are listed below and include non-maintenance medications, all
controlled substances, and self administered injectables. Members may call
Member Services at one of the following telephone numbers, to inquire about
whether specific medications are covered through mail order.
Medications Not Covered Through Mail-Order
Antibiotics
Examples include - Amoxil, Augmentin, Biaxin, Ceclor, Ceftin, Duricef, Dynapen,
Erythromycin, Keflex, Lorabid, Omnicef, Pediazole, Pen Vee K, Principen,
Trimox, Veetids, Zithromax, Zyvox
Antiemetics Examples include -
Anzemet, Emend, Kytril, Zofran
Antifungals Examples include - Diflucan,
Griseofulvin, Lamisil, Nizoral, Nystatin, Sporanox, Vfend
Cancer Drugs
(oral) Examples include – Gleevec, Iressa, Nexavar, Sutent, Sprycel,
Tarceva, Temodar, Tykerb, Xeloda, Zolinza (does not include Nolvadex
(tamoxifen))
Controlled Substances All controlled substances are
excluded from mail-order. Examples include drugs in the following classes:
* Opioids – Darvocet, MS Contin, Opana, Opana ER, Oxycontin,
Percocet, Vicodin * Antianxiety – Ativan, Valium, Xanax
* Stimulants
– Adderall, Adderall XR, Concerta, Focalin, Focalin XR, Provigil, Ritalin,
Ritalin LA, Vyvanse * Cannabinoids – Marinol
* Anabolic Steroids
– Androderm, Androgel, Testim
* Sleep aids – Ambien, Ambien CR,
Lunesta, Restoril, Sonata
* Miscellaneous – Lyrica Drugs
Dispensed in Limited Quantities Examples include – Accutane and
generic, Clozaril, Elidel, Protopic
Drugs Not Approved for Routine Long
Term Use (non-maintenance) Examples include – Amitiza, Cialis, Levitra,
Lotronex, Muse, Toradol (and generic), Valcyte, Valtrex, Vesanoid, Viagra
Drugs with Restricted Distribution Examples include – Revlimid,
Thalomid, Xyrem
High Cost Drugs Drugs with a total cost over $1,500
require prior authorization. Examples include – Exjade, Kuvan, Rilutek,
Revatio, Tracleer, TOBI, Pulmozyme
Migraine Relief Drugs Examples
include – Amerge, Axert, Cafergot, D.H.E 45, Ergotamine, Frova, Imitrex,
Maxalt, Maxalt MLT, Midrin, Migral, Migranal, Relpax, Sansert, Zomig, Zomig ZMT
Self Administered Injectables Examples include – Actimmune,
Apokyn, Arixtra, Avonex, Betaseron, Caverject, Copaxone, D.H.E. 45, Edex,
Enbrel, Epogen, Forteo, Fragmin, Fuzeon, Genotripin, Heparin, Humatrope,
Humira, Infergen, Innohep, Intron-A, Kineret, Leukine, Lovenox, Methotrexate,
Miacalcin, Neupogen, Norditropin, Normiflo, Nutropin, Nutropin Depot, Pegasys,
PEG-Intron, Procrit, Protropin, Rebif, Saizen, Sandostatin, Serostim, Somavert,
Vivaglobin
Miscellaneous Agents Examples include - Ana-Kit, EpiPen,
EpiPen Jr, Twinject Glucagon Emergency Kit Diaphragms Spacers for inhalers This
is not meant to be a complete list of the drugs excluded from mail-order
coverage under your plan, these are examples in each class. Determination of
maintenance medications is defined by the health plan. This list is subject to
change. . |
