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Provider Manual

General Exclusions

Last Updated on May 18, 2021

Most Family Health Center drug benefit policies are subject to the following exclusions (this list is not all-inclusive):

  • Claims submitted with dates of service older than 15 months 
  • Combination medications, unless specifically included on the formulary 
  • Drugs applied, ingested or administered while the member is a patient in a licensed hospital, rest home, extended care facility, convalescent hospital, skilled nursing facility or a similar institution 
  • Drugs dispensed by nonaffiliated pharmacies 
  • Drugs for enhancement of athletic performance 
  • Infertility drugs (male and female) 
  • Investigational/experimental medications 
  • Medical foods 
  • Medication for cosmetic purposes 
  • Medication with no FDA indication 
  • Over-the-counter medications 
  • Replacement medications (lost, stolen, or damaged) 
  • Take-home drugs and supplies dispensed by the hospital at the time of hospital discharge for use at home 
  • Vitamins
  • Weight management medications