Limitations and Exclusions

Participating and nonparticipating pharmacies or mail-order benefits are not provided for:

1. Prescription or nonprescription vitamins, cosmetics, or nutritional supplements.
2. Drugs or medications furnished by a physician or dentist, or drugs dispensed during an inpatient admission by a hospital, skilled nursing facility, sanatorium, or other facility.
3. Over-the-counter (nonlegend) drugs, meaning drugs for which a physician's prescription is not required by law, except as provided for under "Tobacco Cessation Program" on page 83.
4. Fertility drugs.
5. Prescriptions used to treat impotence, except as provided for under "Erectile Dysfunction" on page 60.
6. Weight reduction drugs.
7. Infusion therapy, except as provided for under "Infusion Therapy" on page 65.
8. Fluoride and other dental-related medications.
9. Smoking deterrents, except as provided for under "Tobacco Cessation Program" on page 83.
10. Delivery or handling charges.
11. Prescriptions filled in excess of the number prescribed by the physician, prescription drugs prescribed either by someone who is not allowed by the state to prescribe such prescription drugs or by a provider who is not covered under this plan, or any refill after one year from the date of the physician's order.
12. Appliances, devices and other nondrug items including, but not limited to, therapeutic devices and artificial appliances, except as provided for under "Medical Supplies" on page 66 and "Prosthetic Devices and Artificial Limbs" on pages 73-74.
13. Experimental or investigative drugs including compound medications for non-FDA approved use.
14. Drugs that are not medically necessary or clinically proven for the treatment of an illness, injury or other covered condition.
15. Drugs or medications for which reimbursement is provided by any federal government, state, county, municipality, or special district, or Medicare.
16. Drugs prescribed for chemical dependency, except as provided for under "Chemical Dependency" on pages 55-56.
17. Biologicals, blood, or blood plasma, except as provided for under "Blood" on page 55.
18. Drugs for cosmetic purposes.
19. Antigen and allergy vaccines or serums, except as provided for under "Physician Services" on page 71.
20. Immunizing agents, except as provided for under "Routine Immunizations" on page 79.