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e e : I " . ~ ~. H U M'a naP. PO' R X'4:prescriPtion."oru.g' C()verage Level One - $10, Level Two - $25, Level Three - $50, level. Four -: 25% How the Rx4 structure works Covered prescripoon drugs are assigned to one of four difterent levels with corresponding copaymem amounts. The levels are organized as tollows: . Level One: lowest copayment for low COSt generic and brand-name drugs. . Level Two: higher copayment "tor higher cost generic and br:md-name drugs. . Level Three: higher copayment than Level Two for higher cost. mostly br:md-name drugs that may have generic or brand-name alternatives 011 Levels One orTwo. . Level Four: highest copayment tor high-technology drugs (certain brand-name drugs, bioteclmology drugs and self-administered injectable medications). . Medications may be moved from one level to a different level during the plan year. Please check our Web site or contact Customer Service for the most up-to-date information. Some drugs in all levels may be subject ro dispensing limit:ltions. based on age, gender. duration or q'u.1nrity. Additionally, some Level Four drugs may need prior authorization ill order to be covered. III these cases, your physician should contact Humana Clinical Pbarmacy Review at '1-800-555-CLlN (2546). Members can visit Hum,1na's Web site, www.humana.com. to obtain intormation abom thc::ir prescription drug and corresponding benefits and for possible lower cost alternatives, or they can call Humanas CustOmer Service with questions or to request a Humana Rx4 Drug List by mail. We will also work with physicians and pharmacists to e.."\.l'lain the Rx4 structure. For a complete listing of participating pharmacies, please refer to our Web site or your participating provider directory. Coverage at participating pharmacies When you present your membership card at a participating pharmacy, you are required to make a copayment for each prescription based on the current assigned level of the drug. Drugs assigned to: Copayment per prescription or refill Level One: 810 Levellrvvo: 825 Level Three: S50 Level Four: 25%* of the cotal required payment to the dispensing pharmacy per prescription or refill. * lrhe tota.lma;wl1um out-of-pocket copaymenc costs for drugs in Level Four is limited to $2,500 per calendar year, per member. . If the dispensing pharmacy's charge is less than the corresponding copayment, you will only be responsible tor the lower amount. . Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change ifHumana receives any retrospective volume discounts or prescription drug rebates. There are no claim torms to file if you use a participating pharmacy and present YOllr membership card with each prescription. Nonparticipating pharmacy coverage * You may also purchase prescribed medications from a nonparticipating pharmacy. You will be required to pay for YOllr prescriptions according to tbe following rule. . You pay '100 percent of the dispensing pharmacy's charges. You file a claim torm with Humana (address is on the back ofID card). - Claim is paid at 70 percent of the dispensing phannacy's charges. after they are first reduced by the applicable copayment. . Your copaymenrs for covered prescription drugs are made on a per prescription or refill basis and will not change if Humana receives any retrospective volume discounts or prescription dntg rebates. *" In Georgia. the nonparticipating benefits are paid the same as the participating benefits. per state reguiation. Coverage specifics GN-12140-HH 5/03 Your coverage includes the tollovving: . A 30-day supply or the amount prescribed. vvhichever is less. for each prescription or refill. . Contraceptives. . Certain self-administered injectable drugs and related supplies approved by Humana. . Certain dn.lgs, medicines or medications that, under tederal or Sc,1te la"", may be dispensed only by prescription from a physician.