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') Prescription Medication Benefits AvMm' HEALTH PLANS n $10/20/30n5/50% CO-PAYMENT with Contraceptives OEFINITIONS Brand medication means a Prescription Dmg that is usually m;:mufactured :.md sold under a n:une or trademark by a phannaceutical manufacturer or a medication that is identified a~ a Bnmd medication by AvMed. AvMed delegates detennination of GenericIBrnnd status to our Phannacy Benefits Manager. Bmnd Additional Charge means the additional charge that must be paid if you choose a BidIld medication when a Generic equivalent is available. TIle charge is the difference between the cost of the Brdlld medication and the Generic medication. This charge must be paid in addition 10 the applicable Non- Preferred Bmnd Co-payment. 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 Brand 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 Brcmd Co-payment only. Cost-sharing I\ledkHliolls 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-insurance and coverage is limited as outlined below. Dental-specific Medication is medic,\tion used for dental-specific purposes, including but not limited to fluoride medications ,md medications packaged and labeled for dental-specific purposes. Formulary List means the listing of prefcrred and non-prefcrred medications a'i detennined by AvMed's Pharmacy and 1l1cra~utics Committee based on clinical efficacy, relative safety and cost in comparison to similar medications within a thcrapeutic 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 Phannacy and Therapeutics Committee. Generic medication means a medication that has 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, intnuticular injection, intracavcmous injection or intraocular injection. Prior authorization is required for all Injectable Medications. Maintenance I\kdic-dtion is a medication that has been approved by the FDA, for which the duration of therapy can rc,l'mnably be expected to exceed one year. Participating Phanu3cy means a pharmacy (retail, mail order or specialty phannacy) that has entered into an agreement with AvMed to provide Prescription Drugs to AvMed Members <md has been designated by AvMed as a Participating Phannacy. Prescription Dnlg means a medication that has been approved by the FDA and that can only be dispensed pursuant to a prescription according to state and federal law. Prior Authon7..ation meatls the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMcd's guidelines. The prescribing physician must obtain approval. from AvMed. The list of Prescription Drugs requiring Prior Authorization is subject to periodic review atld 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, an AvMed Participating Phannacy. Your physician should submit prescriptions for Injectable Medications to AvMed's specialty phannacy. Present your prescription along with your AvMed identification card. Pay the following Co-payment (as well as the Brand Additional Charge if you choose a Brand product when a Generic equivalent is available). lier I. Preferred Generic Medications: lier 2 Prefcrred Brand Medications: lier 3 Non~Prcferred Bnmd or Generic Medications: lier 4 Injectable Medications: lier 5 Cost.sharing Medications: OROERING 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 ,m 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 Brcmd Additional Charge if you choose a Brand product when a Generic equivalent is available). $ 10.00 $ 20.00 $ 30.00 $ 75.00 50% Co-payment Co-payment Co-payment Co-payment Co-Insurance lier I lierZ lier3 lier4 lier 5 $ $ Non-Prefen"ed Brand or Generic Medications: $ Injectable Medications are not available through mail. service Cost-sharing Medications are not available through mail service 20.00 40.00 60.00 Co-payment Co-payment Co-payment Preferred Generic Medications: Preferred Brand Medications: A V .LG-RX-2x-1 0I20/30n5/50%-B.09 MP-4000 (10/09)