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<br />Mail-order <br />benefit <br /> <br />e <br /> <br />e <br /> <br />For your convenience. you may receive a ma....amum 90-day supply per prescription or refill through the <br />mail (maximum 3D-day sllpply tor self-administered injectable drugs). The same requirements apply <br />when purchasing m.:dications through a participating mail-order pharmacy as apply when purchasing in <br />person at a pharmacy. Members can call Customer Service or \risit our Web site for more information, <br />including mail-order torms. <br /> <br />Definition <br />of terms <br /> <br />. Drug List: a list of prescription dntgs, medicines. medications and supplies specified by Humana. This list <br />identifies drugs as Level One, Level Two, Level Three or Level FOllr and indicates applicable dispensing <br />limits and/or any prim' authOrization requirements. (This list is subject to change.) <br />. Copaymel1t: the amount to be paid by the member tOlovard the COSt of each separate prescription or refill <br />of a covered drug when dispensed by a phannacy. <br />. Nonparticipating pharmacy: a pharmacy which has not been designated by Hwnana as a <br />partic:iparing pharmacy. <br />. Participating pharmacy: a pharmacy which Iu1s entered into an agreement widl Humana or which has <br />been designated by Humana to provide services to all covered persons. Participating pharmacy desigl1<ltion <br />by Humana may be limiteCl to specified services. <br /> <br />Limitations and <br />exclusions <br /> <br />.. <br /> <br />GN-12140-HH 5/03 <br /> <br />Unless specifically stated otherwise, no coverage is provided for the fo.llO\\o;ng: <br />. Any portion of a prescription or refill that exceeds a 30-day supply for a medication - 90-day supply for a <br />prescription or refill pO-day supply for self-administered injectables) purchased through mail order. <br />. Prescription refills in excess of the number specified by the physician'S original order or dispensed more <br />than one year fium the date of the original order <br />. The administration of a covered medication <br />. Immunizing agents or biological serums or allergy extracts (may be covered under the medical plan) <br />. Infertility drugs (except where required by law) <br />. Drug delivery implants <br />. Any drug, medicine or medication labeled "Caution -limited by federal law to investigational use" or any <br />experime.ntal drug, medicint: or medication, even though a charge is, or may be, made to the member <br />. Any cosrs related to the mailing, sending or delivery of prescription dmgs <br />. Any drug used for weight control (except where required by law) <br />. Any drug pl:escribed for a nOIlcovered sickness or injury <br />. Abortifacienrs (drugs used to induce abortions) <br />. Any dnlg prescribed for impotence and/or sexual dysfunction, e.g.Viagra <br />. Injectable drugs. including but not limited to immunizing agents, biological sera, blood, blood plasma or <br />sdf-administered injectable drugs not approved by Humana <br />. Dietary supplements, except for amino acid modified preparations and Jow-protein modified food <br />products necessary tor the treatment of inherited metabolic diseases. <br /> <br />This is only a partial list of limitations and exclusions. Please refer to the Certificate of <br />Coverage/Insurance for complete details regarding prescription drug coverage. <br /> <br />,,~~- <br /> <br />Insured by Humana Health Insurance Company ofFlorid1, Inc., Hwnana Insurance Company, <br />Humana Health Plan, Inc., or Humana Insurance of Puerto Rico, .Inc. <br /> <br />@20D3 Humana Inc. <br /> <br />HumanaPPO <br />