Alaska Teamster-Employer Welfare and Pension Trusts

8.6 PRESCRIPTION DRUGS THAT ARE LIMITED

1. Progesterone products, including compounded forms.
2. Pharmaceuticals prescribed for treatment of sexual dysfunction that are in excess of the quantity level limits or Utilization Management recommendations established by the Plan’s pharmacy benefits manager. Pharmaceuticals prescribed for treatment of sexual dysfunction are available under the Plan’s Retail Pharmacy Program ONLY; they are NOT available under the Plan’s Mail Order Pharmacy Program.
3. Products for smoking cessation received from a Participating Retail Pharmacy are limited to a 34-day supply. Smoking cessation products received from a Participating Mail Order Pharmacy are limited to a 90-day supply. Smoking cessation products available without a prescription are not covered by the Plan.