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f') Prescription Medication Benefits, continued WHAT IS COVERED? . Your Prescription Drug coverage includes outpatient medications (including contrJ.ceptives) that require a prescription and are prescribed by your AvMed physician in accordance with AvMed's coverage criteria. AvMed reserves the right to make changes in coverage criteria for covered pnx:lucts and services. Coverage criteria arc medical and pharmaceutical protocols used to dctcnnine payment of producto; and services and are based on independent clinical practice guidelines and standards of care established by government agencies and medicallphmmaceutical societies. . Your Prescription Drug coverage may require Prior Authorization, including the Progressive Medication Program, for certain covered medications. The Progressive Medication Progr.un encourages the use of theiJpcutically-equivalent lower-cost medications by requiring certain medications to be utilized to treat a medical condition prior to approving another medication for that condition. This includes the first-line use of preferred medications that are proven to be safe and effective for a given condition and can provide the same health benefit as more expensive non-preferred medications at a lower cost. Your retail Prescription Drug coverage includes up to a 3D-day supply of a medication for the listed Co-payment. Your prescription may be refilled via re~'lil or mail order after 75% of your previous fill has been used and subject to a maximum of 13 refills per year. You also have the opportunity to obtain a 90-day supply of medications used for chronic conditions including, but not limited to asthma, cardiovascular disease, and diabetes from the retail pharmacy for the applicable Co-payment per 3D-day supply. However, Prior Authorization may be required for covered medications. . Your mail-order Prescription Drug coveiJge includes up to a 90-day supply of a routine maintenance medication for the listed Co-payment. [f the amount o of medication is less than a 90-day supply, you will still be charged the listed mail order Co-payment. . Your Injectable Medication coveiJge extends to many injectable medications approved by the FDA. These medications must be prescribed by a physici;:m and dispensed by a retail or specialty phannacy. The Co-payment levels for Injectable Medications apply regardless of provider. This means that you arc responsible for the appropriate Co-payment whether you receive your Injectable Medication from the phannacy, at the physician's office or during home health visits. Injectable Medications are limited to a 3D-day supply. . Your Prescription Drug coveiJge includes coverage for injectable contraceptives. There is a Co-payment of $30 for each injection. If there is an office visit associated with the injection, there will be an additional Co-payment required for the office visit. . Quantity limits are set in accordilllce with FDA approved prescribing limitations, general practice guidelines supported by medical s~cialty organizations, and/or evidence-based, statistically valid clinical studies without published conflicting data. This means that a medication-specific qmmtity limit may apply for medications that have an increased potential for over-utilization or an increased potential for a Member to experience an adverse effect at higher doses. QUESTIONS? Call your AvMed Member Services Department at: t -800-88-AvMed (1-800-882-8633) EXCLUSIONS AND LIMITATIONS . Medications which do not require a prescription (i.e. over-the-counter medications) or when a non-prescription alternative is available, unless otherwise indicated on AvMed's Fonnulary List. . Medications not included on AvMed's Fonnulary List. . Medical supplies, including therapeutic devices, dressings, appliances and support garments . Replacement Prescription Drug products resulting from a lost, stolen, expired, broken or destroyed prescription order or refill . Diaphragms and other contraceptive devices . Fertility drugs . Medications or devices for the diagnosis or treatment of sexual dysfunction . Dental-specific Medications for dental purposes, including fluoride medications . Prescription and non-prescription vitamins and minerals except prenatal vitamins . Nutritional supplements . Immunizations . Allergy serums, medications administered by the Attending Physician to treat the acute pha<;e of illl illness and chemotherapy for cancer patient" are covered in accordance with the Group Medical and Hospital Service Contract and may be subject to Co-payments or Co-insurance as outlined on the Schedule of Benefits . Investigational and experimental drugs (except as required by Ronda statute) . Cosmetic products, including, but not limited to, hair growth, skin bleaching, sun dmnage and anti-wrinkle medications . Nicotine suppressants ;:md smoking cessation products and services . Prescription and non-prescription appetite suppressants and products for the purpose of weight loss . Compounded prescriptions, except pediatric preparations . Medications and immunizations for non-business related travel, including Transdennal Scopolamine Filling a prescription at a phannacy is flot a cfaimfor benefits and is 1Iot subject to the Claims and Appeals procedures Willer ERISA. Howel'er, WI)' medicines thaf require Prior {/uthon.wtioll will be treated as a claim for benefits subject to the Claims and Appeals Pmcedllres, as outlined in the Gmup Medical and Hospital Se/vice Contract. A V -LG-RX-2x:-1 O/20/30n5/50%-09 MP-4000 (10/09)