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f) Prescription Medication Benefits AvMED. HEALTH PLANS o $1 O/20130nS/50% CO.PAYMENT with Contraceptives DEFINITIONS llnmd medication means a Prescription Drug that is usually manufactured and sold under a name or trademark by a phannaceutical manufacturer or a medication that is identified as a Brand medication by AvMed. AvMed delegates determination of GcnericIBmnd status to our Ph,mllilcy Benefils Manager. Hrand Additional Char~c me;ms the additional charge that must be paid if you choose a Bmnd medication when a Generic equivalent is available. The charge is the difference between the cost of the Brand medication and the Generic medication. This charge must be paid in addition to the applicable Non. Preferred Brand Co-pa)1ncnt. However, if the prescribing physician or other Participating Provider authorized to prescribe medications within the scope of his or her license indicates on the prescription Bnmd medically necessary or dispense as written for a medication for which there is a generic equivalent, the Brand medication shall be dispensed for the applicable Non-Preferred Brdfld Co-payment only. Cost-sharing Medications are those medications, as designated by AvMed, which were designed to improve the quality of life by treating relatively minor non-life threatening conditions. Such medications are subject to Co-insurnnce and covemge is limited as outlined below. Dental.specUic I\.'lcdication is medication used for dental-specific purposes, including but not limited to fluoride medications and medications packaged and labeled for dental-specific purposes. Formulary List means the listing of preferred and non-preferred medications as detemlincd by AvMed's Phannacy and Therapeutics Committee based on clinical efficacy, relative safety and cost in comparison to similar medications within a therapeutic class. This multi-tiered list establishes different levels of Co-payment for medications within therapeutic classes. As new medications become available, they may be considered excluded until they have been reviewed by AvMed's Pharmacy and Therapeutics Committee. Generic medication me,ms a medication that ha<; the same active ingredient as a Brand medication or is identified as a Generic medication by AvMed's Pharmacy Benefits Manager. Injectable Medication is a medication that has been approved by the Food and Drug Administration (FDA) for administration by one or more of the following routes: intramuscular injection, intravenous injection, intravenous infusion, subcutaneous injection, intrathecal injection, intrarticular injection, intracavemous injection or intraocular injection. Prior authorization is required for all Injectable Medications. Maintenance Medication is a medication that has been approved by the FDA, for which the duration of therapy can reasonubly be expected to exceed one year. Pm1icipating Phanuacy means a pharmacy (retail, mail order or specialty ph;:mnacy) that has entered into an agreement with AvMed to provide Prescription Drugs to AvMed Members and has been designated by AvMed as a Participating Phannacy. Prescription nrug means a medication that has been approved by the IDA and that can only be dispensed pursuant to a prescription according to state and federal law. Prior Authorization means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMed's guidelines. The prescribing physician must obtain approval from AvMed. The list of Prescription Drugs requiring Prior Authorization is subject to periodic review llild modification by AvMed. A copy of the list of medications requiring Prior Authorization and the applicable criteria are available from Member Services or from the AvMed website. HOW DOES YOUR RETAIL PRESCRIPTION COVERAGE WORK? To obtain your Prescription Drug, take your prescription to, or have your physician call, llil AvMed Participating Pharmacy. Your physician should submit prescriptions for Injectable Medications to AvMed's specialty pharmacy. Present your prescription along with your AvMed identification card. Pay the following Co-payment (as well a<; the Brand Additional Charge if you choose a Brand product when a Generic equivalent is available). TIer 1 Preferred Generic Medications: TIer 2 Preferred Brand Medications: TIer 3 Non-Preferred Brand or Generic Medications: Tier 4 Injectable Medications: Tier 5 Cost~sharing Medications: ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL Mail service is a benefit option for maintenance medications needed for chronic or long-tenn health conditions. It is best to get an initial prescription filled at your retail pharmacy. Ask your physician for an additional prescription for up to a 90-day supply of your medication to be ordered through mail service. Up to 3 refills are allowed per prescription. Pay the following Co-payment (as well as the Brnnd Additional Charge if you choose a Brand product when a Generic equivalent is available). $ to.oo $ 20.00 $ 30.00 $ 75.00 50% Co-payment Co-payment Co-payment Co-payment Co-Insurance Tier 1 TIer 2 TIer 3 Tier 4 TierS Preferred Generic Medications: Preferred Brnnd Medications: 20.00 40.00 60.00 Co-payment Co-payment Co-payment $ $ Non-Preferred Bnmd or Generic Medications: $ Injectable Medications are not available through mail service Cost-sharing Medications arc not available through mail service A V -LG-RX.2x-1 0I20/30nS/50%-B-09 MP-4000 (10109)