| Drugs when used for anorexia, weight loss, weight gain |
Orlistat is covered under prior authorization with medical justification |
| Drugs when used to promote fertility |
Drugs with fertility only FDA approved indications are not covered: drugs with fertility and non-fertility FDA approved indications are covered |
| Drugs when used for cosmetic purposes or hair growth |
Drugs with cosmetic only FDA approved indications are not covered;
Isotretinoin is covered for medical necessity with medical justification |
| Drugs when used for the symptomatic relief of cough and colds |
Generic drugs classified by First Data Bank (FDB) as cough and cold agents (Therapeutic Generic Class=50) are covered; brand drugs classified by FDB as cough and cold are not covered. |
| Prescription vitamins and mineral products |
Prenatal vitamins and fluoride preparations, renal vitamins and vitamin preparations in Total Parenteral Nutrition are covered. |
| Nonprescription drugs (Over-the-Counter) |
Rebateable, non-DESI, anthelminics, nasal antiallergens, non-repackaged antacids and adsorbents, topical antifungals, antihistamines, topical anti-inflammatory agents, topical antibiotics, antidiarrheal agents, insulins, iron preparations, niacin, nonsteroidal anti-inflammatory agents, calcium replacement preparations, topical keratoplastic agents, acetaminophen, nutritionally complete products used for inborn errors of metabolism, topical scabicides and pediculisides, optical vasoconstrictor agents, proton pump inhibitors and other specialized nutritional products are covered with prior authorization |
| Barbiturates |
Generic barbiturates |
| Benzodiazepines |
Generic benzodiazepines |
| Smoking Cessation |
None |