Label Drugs. When prescribed for an individual with a life-threatening or chronic and disabling condition or disease benefits are provided for the following: • Off-label drugs; and • Medically Necessary services associated with the administration of such a drug. An off-label drug is one that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the U.S. Food and Drug Administration (FDA). All off-label drugs must be pre-approved by Alliant Health Plans. OTHER PROGRAM PROVISIONS Should the Member, on his or her own accord, choose a Brand Name Drug over a generic drug, regardless of whether a generic equivalent is available and even if the Physician orders the drug to be “dispensed as written,” the Member will pay the Copayment for the Brand Drug as outlined in the Summary of Benefits and Coverage, PLUS the difference in the cost of the two drugs. OUTPATIENT PRESCRIPTION DRUG BENEFITS DO NOT INCLUDE THE FOLLOWING: • Prescription Drug products for any amount dispensed which exceeds the FDA clinically recommended dosing schedule; • Prescription Drugs received through an Internet pharmacy provider or mail-order provider except for Our designated mail order provider; • Newly approved FDA drugs that have not been approved for at least 180 days; • Non-legend vitamins; • Over-the-counter items; • Cosmetic drugs; • Appetite suppressants; • Weight loss products; • Diet supplements; • Syringes (for use other than insulin) except when in coordination with an approved injectable; • Injectables (except with Prior Authorization as required); • The administration or injection of any Prescription Drug or any drugs or medicines; • Prescription Drugs which are entirely consumed or administered at the time and place where the prescription order is issued; • Prescription refills in excess of the number specified by the Physician, or any refill dispensed after one year from the date of the prescription order; • Prescription Drugs for which there is no charge; • Charges for items such as therapeutic devices, artificial appliances, or similar devices, regardless of their intended use; • Prescription Drugs for use while an Inpatient or Outpatient of a Hospital. • Prescription Drugs provided for use in a convalescent care facility or nursing home which are ordinarily furnished by such facility for the care and treatment of Inpatients; • Charges for delivery of any Prescription Drugs; • Drugs and medicines which do not require a prescription...
Label Drugs. A Prescription Drug prescribed for a use that is not stated in the indications and usage information published by the manufacturer is covered only if the drug is:
