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I') Prescription Medication Benefits, continued WHAT IS COVEREO? . Your Prescription Drug covemge includes outpatient medications (including contraceptives) that require a prescription and arc prescribed by your AvMed physician in accordance with AvMed's covernge criteria. AvMed reserves the right to make changes in covemge criteria for covered products and services. Coverage criteria are medical ,md pharmaceutical protocols used to dctennine payment of products and services and are based on independent clinical pmcticc guidelines and standards of care established by government agencies and mcdicallph.mnaccutical societies. . Your Prescription Drug coverage may require Prior Authorization, including the Progressive Medication Progrrun. for certain covered medications. The Progressive Medication Progmm encourages the use of therapeutically-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 Dmg coverage includes up to a 3D-day supply of a medication for the listed Co-payment. Your prescription may be refilled via retail 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 a<;thma, cardiovascular disea<;e, 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 coverage includes up to a 90-day supply of a routine maintenance medication for the listed Co-payment. If the amount of medication is less than a 90-day supply, you will still be charged the listed mail order Co-payment. t-) . Your Injectable Medication coverage extends to many injectable medications approved by the FDA. These medications must be prescribed by a physician lmd dispensed by a retail or specialty pharmacy. The Co-payment levels for Injectable Medications apply regardless of provider. This means Ihal you are responsible for the appropriate Co-payment whether you receive your Injectable Medication from the phannaey, at the physician's office or during home health visits. Injectable Medications are limited to a 3D-day supply. . Your Prescription Dmg coverage includes covemge for injectable contraceptives. There is a Co-payment of $30 for each injection. If there is ,m office visit associated with the injection, there will be an additional Co-payment required for the office visit. . Quantity limits are set in accordance with FDA approved prescribing limitations, general practice guidelines supported by medical specialty org;:mizalions, anellor evidence-based, statistically valid clinical studies without published conflicting data. This means that a medication-specific quantity 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: 1-800-88-AvMed (1-800-882-8633) EXCLUSIONS ANO 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 FOffimlary List. . Medical supplies, including therapeutic devices, dressings, appliances and support garments . Replacemenl Prescription Drug products resulting from a lost, slolen, 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 phase of an illness and chemotherapy for cancer patients are covered in accordance wilh 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 Florida statute) . Cosmetic products, including, but not limited to, hair grO\vth, skin bleaching, sun damage and anti-wrinkle medications . Nicotine suppressants and 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 ffild immunizations for non-business related travel, including Tfllilsdennal Scopolamine Filling (/ prescription at a phan/Jac)';s Ilot a clllimfor benefits alld is llOt subject to the Claims and Appeals procedures IInder ERISA. However. all)' medicines that require P,10ralltllOrizat;Oll will be treated as a claim for benefits subject to the Claims (Il1d Appears P/Vcedllres. as olltlil/ed ill the Group Medical and Hospital Service COlltmct. A V -LG.RX-2x-1 O/20/30n5/50%-09 MP-4000 (10/09)