The prescription drug benefit program does not cover the following:

1. Services or supplies (including drugs) subject to the General Exclusions applicable to all benefits.
2. Drugs or medicines procured or that are procurable without a physician’s written prescription, including all “Over the Counter” (OTC) drugs which are not prescribed by a doctor, except as noted under Covered Drugs.
3. Nose drops or nasal preparations that do not require a written prescription.
4. Contraceptives or contraceptive materials, including birth control pills, are not covered, but if medically necessary, may be covered under the medical portion of the Plan.
5. Immunization agents.
6. Appliances or prosthetics (canes, crutches, walkers, etc.).
7. Any non-drug item, proprietary medicines, biological sera, dietary supplements, vitamins or health and beauty aids.
8. Drugs dispensed by a hospital, nursing home, clinic, ambulatory surgical center, doctor or other institution.
9. Drugs obtained after coverage terminates.
10. Devices utilized to administer drugs except as noted under Covered Drugs.
11. Drugs dispensed to a dependent child as a result of a pregnancy.
12. Any prescription or refill which considered individually, or cumulatively within a time frame, authorizes dosages which exceed the Food and Drug Administration (FDA) or the manufacturer’s recommendations.
13. Chemotherapy drugs are not covered as a prescription drug benefit, but may be covered under the medical portion of the Plan.
14. Smoking deterrents or treatments are not covered, but if medically necessary may be covered under the medical portion of the Plan.
15. Minoxidil or Retin A for cosmetic purposes.
16. Drugs used as part of a drug treatment or drug therapy program.
17. Drugs labeled “caution - limited by Federal Law to investigational use,” or experimental drugs.
18. Over the counter fluoride preparations (stannous fluoride, etc.).
19. Benefits will not be coordinated with other plans. If benefits are paid, or are payable, under any other plan, this Plan will not pay.
20. Drugs prescribed for treatment of conditions, including experimental uses, which are not within the indicated uses approved by the Food and Drug Administration or the manufacturer.