Expenses not covered under all UHC Plans
The plan does not cover the following:
- Drugs or medicines lawfully obtainable without a prescription, except for covered OTC preventive care medications and supplements or OTC contraceptives
- Diagnostic kits and products including associated services.
- Injectable medication and chemotherapy agents administered by a physician or healthcare professional; these medications are generally covered under the medical plan (injectable medications that are commonly self-administered, like insulin, are covered under the prescription plan.)
- Over-the-counter smoking cessation products and smoking cessation medications not prescribed by a physician, or for dependents under age 18, or filled at a non-network pharmacy
- Any drug considered to be experimental or investigational by the Food and Drug Administration (FDA) or medications used for experimental indications and/or dosage regimens considered to be experimental
- Certain new pharmaceutical products and/or new dosage forms until the date as determined by the claims administrator's designee, but no later than December 31st of the following calendar year.
This exclusion does not apply if you have a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment).
- Durable medical equipment and prescribed and non-prescribed outpatient supplies other than disposable insulin syringes, insulin pen injectors, needles, insulin pump syringes/ needles, lancets and test strips prescribed with injectable insulin (see the Medical Plan section for durable medical equipment coverage).
- A pharmaceutical product for which benefits are provided in the medical portion of the Plan. This includes certain forms of vaccines/immunizations. This exclusion does not apply to Depo Provera and other injectable drugs used for contraception.
- Immunization agents, biological sera, allergens, allergenic extracts (oral or injectable) and blood or blood plasma (generally covered under the medical plan). Note: effective January 1, 2020, certain adult immunizations / vaccines are covered under the pharmacy benefit at 100%.
- Any medication administered and entirely consumed in connection with direct patient care rendered in the home by licensed healthcare professionals (These medications are generally covered under the medical plan.)
- More than a 31-day supply of a covered drug from a retail pharmacy, or more than a 90-day supply of a covered drug from the home delivery program
- Any medication consumed or administered at the place where the prescription is written, including medication taken or administered while the individual is in a licensed hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home or similar institution
- Any covered drug in excess of the quantity specified by the physician, or any refill dispensed after one year from the physician's original order
- Any product used for cosmetic purposes without prior approval from UnitedHealthcare
- Any charge for the administration of covered prescription drugs
- Any drug that may be covered under local, state or federal programs, including Workers' Compensation
- Any amounts over the allowable UnitedHealthcare discounted drug cost
- General vitamins, except prenatal vitamins, vitamins with fluoride, vitamins provided at no cost as described under "Preventive Care Medications," and single entity vitamins that require a prescription
- Compounded drugs that contain certain bulk chemicals. Compounded drugs that are available as a similar commercially available pharmaceutical product. Compound prescriptions over $50 are not covered unless prior authorization.
- A prescription drug product that contains an active ingredient available in a therapeutically equivalent to another prescription drug product. Such determinations may be made up to six times during a calendar year, and UnitedHealthcare may decide at any time to reinstate benefits for a prescription drug product that was previously excluded under this provision
- A prescription drug product that contains an active ingredient which is a modified version of and therapeutically equivalent to another prescription drug product. Such determinations may be made up to six times during a calendar year, and UnitedHealthcare may decide at any time to reinstate benefits for a prescription drug product that was previously excluded under this provision
- Prescription drugs with an OTC equivalent.
- Dental products, with the exception of prescription fluoride topicals in certain circumstances.
- Certain prescription drug products for which there are therapeutically equivalent alternatives available, unless otherwise required by law or approved by UnitedHealthcare. Such determinations may be made up to six times during a calendar year, and UnitedHealthcare may decide at any time to reinstate benefits for a prescription drug product that was previously excluded under this provision.
- Certain unit dose packaging or repackagers of prescription drug products.
- Certain Prescription Drug Products that are FDA approved as a package with a device or application, including smart package sensors and/or embedded drug sensors. This exclusion does not apply to a device or application that assists you with the administration of a prescription drug product.
Medications may be excluded from coverage under your pharmacy benefit when it works the same or similar as another prescription medication or an over-the counter (OTC) medication. The UnitedHealthcare/OptumRx™ Advantage PDL provides a list of excluded medications. For an up-to-date Advantage PDL, visit www.myuhc.com or call UnitedHealthcare at 800 387 7508.
If an excluded drug is prescribed for a specific medical condition, you may qualify for an exception. To request an exception, submit a letter to UHC from your doctor stating the medical condition that requires the non-covered drug and the length of projected use. The maximum time for which a letter can justify an exception is 12 months. If your exception is approved, you will be able to purchase your prescription at your local network pharmacy or by mail order by paying the applicable copay or coinsurance amount.