SSMC Employee Health Benefit Plan
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attending Physician and found Medically Necessary. Some drugs require pre-authorization before benefits
become available. See Pre-authorization Requirements shown later in this section. Also, see Prescription
Drug Expense Exclusion shown later in this section. Coverage is provided for the following:
a. Medications that require a prescription by a licensed Physician and are Federal legend drugs.
b. Compounded medications containing at least one prescription ingredient in therapeutic amounts.
c. Prenatal prescription vitamins, Tri-vi-flor (Pediatric vitamins an fluoride). Other legend vitamins are
covered when found Medically Necessary for treatment of specific Illness or Injury and not
supplementation.
d. Fluoride Prep and Dental Rinses.
e. Hematological agents ( folic acid or iron).
f. Diabetic insulin, syringes, alcohol swabs, hypoglycemia rescue agents, testing agents, lancet
autoinjectors, lancets, insulin auto injectors and needles, glucose monitoring machines, and related
Supplies. Pumps are covered separately under Diabetic Supplies, Equipment and Education shown
previously in this section.
g. Injection delivery devices (syringes) for uses other than diabetic when necessary for self-administration
of Covered injection legend drugs.
h. Retin A or similar drug to the age of 27 for Medical Necessity with a prescription. Pre-authorization is
required for Covered Persons age 27 or older.
i. Smoking deterrents (patches, gum and pills) obtained with a prescription (90 days maximum per
Lifetime).
j. Allergy emergency kits for Emergency treatment of insect stings in allergic patients.
k. Anti-migraine agents, i.e., Imetrex, limited to six kits/month or two blister packs (18 tabs) per month.
l. Drugs for treatment of impotency, Caverject, Muse, Edex and forms of Testosterone used for treatment
of impotence. Viagra or similar drug with written prescription.
m. Prescription contraceptives; birth control pills, patches, devices (Implantable time-released medication,
i.e., Norplant, not covered)
n. Aminoacidopathies formula for certain metabolic disorders.
o. Fertility drugs, oral and injectable (Pre-authorization required)
p. Growth Hormones (Pre-authorization required)
q. Immune response modifiers (Pre-authorization required for Betaseron and Avonex),
2. Pre-authorization Requirements. Some drugs require pre-authorization before benefits become
available. The Network or Mail Service Pharmacy will not provide coverage unless these drugs have been
approved for benefit payment. If a Pharmacy advises that you need pre-authorization, a letter of Medical
Necessity from your attending Physician should be sent to the Clinical Department at EHS. Benefits will
become available based on the review by EHS, clinical department. The following is a partial list of drugs
that require pre-authorization:
Biotech drugs (i.e., Capaxone)
Fertility drugs
Growth hormones
Lovenox or similar drug.
Immune response modifiers (Betaseron, Avonex)
3. Voluntary Generic Drug Substitution Program. As part of a continuing effort to control costs and
preserve the quality of the Plan, you are encouraged to use Generic Drugs whenever appropriate for your
condition. A Generic Drug is a drug that is chemically equivalent to the original brand name drug. The
only difference is that the patent on the brand name medication has expired allowing other manufacturers to
sell the drug. As a result, the generic manufacturer does not incur research costs and can charge
significantly less for the drug. Since Generic drugs cost less than brand name drugs, cost savings may
result for you and the Plan when you substitute the lower priced drug. If you have any questions about
generic replacements, ask for advice from your Physician or your pharmacist.
