Your session is about to expire due to inactivity.
Health Fund

What's Not Covered

What's Not Covered

The following is a list of charges that are not covered by the prescription drug program:

  1. Any charge for the administration of a prescription drug or injectable insulin;
  2. Any medication, prescription or otherwise, that is consumed or administered at the place where it is dispensed, such as;
    • Botulinum Toxin A (Botox) (unless approved for certain conditions, contact the Fund office to obtain a Medical Review); or
    • Botulinum Toxin B (Myobloc) (unless approved for certain conditions, contact the Fund office to obtain a Medical Review);
  3. Charges you or your dependents aren't required to pay;
  4. Contraceptives not prescribed by a physician;
  5. Cosmetic hair growth removal products;
  6. Depigmenting agents;
  7. Drugs labeled: "Caution - limited by Federal Law to investigational use" or experimental drugs, even though the drug was prescribed by their physician;
  8. Hair-growth stimulators;
  9. Immunization agents (except for Synagis), biological sera, blood or blood plasma;
  10. Items that may be purchased without a written prescription ("over the counter").   Exception is the over-the-counter drugs covered under Preventive Care Services, see page 69.
  11. Loratadine products;
  12. Medication that is to be taken by or administered to an individual, in whole or in part, while he/she is a patient in a licensed hospital, nursing home, mental health facility, extended care facility, convalescent hospital, rest home or similar institution that operates a facility for dispensing pharmaceuticals on its premises;
  13. Naturopathic medicine/Naturopathy services;
  14. Non-sedating antihistamines, such as Allegra, except in select cases when your physician provides a letter explaining why the prescribed drug is medically necessaryMedical treatment that satisfies the definition of "necessary treatment." and why the over-the-counter version is not an effective alternative for his/her patient. Contact the Fund office to obtain a Medical Review;
  15. Obesity treatment medications;
  16. Over-the-counter medications, such as Tylenol, Colace, etc.;
  17. Prescription drugs taken for cosmetic reasons;
  18. Prescription drugs that aren't medically necessary;
  19. Prescription drugs that may be obtained without charge under local, state or federal programs, including Workers' Compensation;
  20. Prescriptions for more than a 30-day supply for retail purchase or a 90-day supply for mail-order (contact the Eligibility Department if you are going to be out of the state or the country for longer than 90 days);
  21. Proton pump inhibitors (PPIs), such as Nexium;
  22. Refilling of a prescription over the amount specified by the physician or
    dentistA doctor of dentistry who is licensed to practice dentistry at the time and place involved where the particular dental procedure was rendered., or any refill purchased more than one year from the date of the prescription;
  23. Testosterone replacement and erectile dysfunction drugs, except in certain cases if your physician provides a letter explaining why the drug is medically necessary. Contact the Fund office to obtain a Medical Review;
  24. Therapeutic devices or appliances, including hypodermic needles, syringes, support garments and other non-medical substances; and
  25. Tretinoin, all dosage forms (e.g., Retin-A) for individuals 26 years of age or older. The use of Retin-A as a treatment for photo-aging (wrinkles) is not covered.

Filing A Claim

You need to file a claim whenever you purchase a prescription at a non-participating pharmacy. Claim forms can be obtained from our website at, click "Forms/Health Fund". You can submit the claim directly to Express Scripts and you will be reimbursed directly by Express Scripts for your out-of-pocket expense, less the applicable copayA fixed dollar amount you pay for an eligible expense at the time the service is provided..


Note:  Over-the-counter medications under Preventive Care Services benefits are covered through the Plan's Pharmacy Benefit Program.