Non-Covered Prescription Drugs

You can purchase certain non-covered prescription drugs for weight or hair loss through an ESI participating pharmacy and pay the discounted rate instead of the full retail amount. This category includes:

Weight Management/Obesity
Xenical - Orlistat
Didrex - Benzphetamine
Tenuate - Diethylpropion
Bontril, Melfiat-105 - Phendimetrazine
Ionamin, Adipex-P, Fastin - Phentermine
Meridia - Sibutramine

Hair Loss Treatment
Propecia

Excessive Hair Treatment
Vaniqa

This list is subject to change.

Prior Authorization

ESI requires prior authorization for specific medications. Prior authorization means proof of medical necessity is required before a prescription for certain drugs is paid by the plan. The purpose is to prevent misuse and the off-label use of expensive and potentially dangerous drugs. If you take a new prescription to the pharmacy and the pharmacist says it requires prior authorization, ask your physician to call ESI’s Prior Authorization line at 800.417.8164 for approval.

Quantity Level Limits

Quantities of some medications may be limited based on recommendations by the Food & Drug Administration (FDA) and medical literature. Limits are in place to ensure safe and effective drug use and guard against stockpiling of medicines. Examples include Viagra, Sporonax, Imitrex, Relenza, Tamiflu, Ambien and Lunesta. The list is subject to revision.

How to File a Claim With ESI

Claims must be filed within 12 months of receiving a prescription. Request a claim form by calling ESI’s or MCHCP’s customer service lines or download a copy.

• Complete the claim form.
• Attach a prescription receipt or label with the claim form. The receipt or label must include:
  • Pharmacy name/address.
  • Patient’s name.
  • Price.
  • Date filled.
  • Drug name, strength, and NDC.
  • Prescription number.
  • Quantity.
  • Days supply.

Patient history printouts from the pharmacy are also acceptable but must be signed by the pharmacist. Cash register receipts are not acceptable for any prescriptions, except diabetic supplies.

Note: The formulary may have new drugs added during the year. Otherwise it remains the same throughout the year, unless:

• A generic drug becomes available to replace the brand name drug. The copayment reflects a change.
• A drug becomes available over-the-counter. It is no longer covered under the pharmacy benefit. ESI must notify member 30 days in advance of any deletions in formulary other than generics.