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r") Prescription Medication Benefits, continued WHAT IS COVERED? . Your Prescription Drug coverage includes outpatient mediC<ltions (including contraceptives) that require a prescription and are prescribed by your AvMcd physician in accordance with AvMcd's covcrnge criteria. AvMed reserves the right to make changes in coverage criteria for covered products and services. Coverage criteria are medical and pharmaceutical protocols used to dctcnninc payment of products and services and are based on independent clinical prnctice guidelines and sl<Uldarus of care established by government agencies and mcdicaVpharmaceutical societies. . Your Prescription Drug coverage may require Prior Authorization, including the Progressive Medication Program. for cCltmn covered medications. The Progressive Medication Program encourages the use of therapeutically-equivalent lower-cost medications by requiring cel1ain 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 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 asthma, cardiova'icular disease, and diabetes from the retail pharmacy for the applicable Co-pa)1ncnt per 3D-day supply. However, Prior Authorization may be required for covered medications. . Your mail-order Prescription DlUg 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, YOll will still be charged the listed mail order Co-payment. . Your Injectable Medication coverage extends to many injectable medications approved by the FDA. 1l1ese medications must be prescribed by a physician and dispensed by a retail or specialty phrumacy. The Co-pa)1nent levels for Injectable Medications apply regardless of provider. This means that you are responsible for the appropriate Co-pa)1nent whether you receive your Injectable Medication from the pharmacy, at the physician's office or during home health visits. Injectable Medications are limited to a 3D-day supply. . Your Prescription Drug coverage includes coverage for injectable contraceptives. There is a Co-pa)1nent of $30 for each injection. If there is an office visit associated with the injection, there will be;m additional Co-pa)1nent required for the office visit. . Qmmtity limits arc set in accordance with fDA approved prescribing limitations, general practice guidelines supported by medical specially organizations, and/or evidence-based, statistically valid clinical studies without published conflicting data. This means that a medication-specific qU<U1tity limit may npply for mcdicntions 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 AND LIMITATIONS . Medications which do not require a prescription (i.e. over-the-counter medications) or when a non-prescription altemative 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 gm111ents . 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 dingnosis or treatment of sexual dysfunction . Dental-specific Medications for dental purposes, including fluoride medications . Prescription and non-prescription vitamins and minerals except prenntal vitamins . Nutritional supplements . Immunizations . Allergy serums, medications ndministercd by the Attending Physici,mto treat the acute phase of an illness and chemotherapy for cancer patients 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 Rorida 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 <md 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 phanllac)' is /lOt a claim for benefits (lnd is not subject to the Claims and Appeals procedures flllder ERISA. Howel'er, an)' medicines that require Prior authorization will be treated as a claim for belle fits subject to the Claims ami Appeals Procedures, as ol/tlined ill the Group Medical alld Hospital Serdce Contract. A V -LG-RX-2x. J OnO/30n 5/50%-09 MP-4000 (10/09)