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... ....... . . . . . :1 .~ . '" :. : .. .:. ~. ~ . . Hum a naP P O' R x 4 . pre~crip'tion .D.r~g' co~erag~ : .,:;:: level One - $10. level Two - $25. [ev~1 Three - :$50, level' Four _: 2~.% .r. ';. How the Rx4 structure works Covered prescnpaon drugs are assigned to one of four difterem levels with corresponding copaymem amounts. The levels are organized as ,follows: . Level One: low-est copaymem for low COSt generic and brand-name drugs. . Level Two: higher copayment tor higher cost generic and br:md-name drugs. . Level Three: higher copaymem than Level Two tor higher cost. mostly brand-name drugs that may have generic or brand-name alternatives on Levels One or Two. . Level Four: highest copayrnent for high-technology drugs (cerrain br:md-name drugs, biOtechnology drugs and self-administered injectable medications). . Medications may be moved from one level to a clifterent level during the plan year. Please check Ollr Web site or contact Customer Service for the most up-to-date information. Some drugs in all levels may be subject co dispensing limit::ltions. based on age, gender, duration or quantity. Additionally, some Level Four drugs may need prior authorization in order to be covered. In these cases. your physician should conract Humana Clinical Pharmacy Review at '1-800-555-CLIN (2546). Members can visit Hum:ma's Web site, W\vw;humana.com, to obtain intormation about tl1eir prescription drug and corresponding benefits and for possible lower cost alternatives, or they can call Humana's Customer Service with questions or to request a Humana Rx4 Drug List by mail. We will also work with physicians and pharmacists to eAl'lain the Rx4 strucnn-e. 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 req\lired to make a copayment for each prescription based on the currem assigned level of the drug. Drugs assigned to: Copayment per prescription or refill Level One: S10 Level Two: $25 Level Three: 550 Level Four: 25%* of the total required payment to the dispensing pharmacy per prescription or refill. * The total maximum our-of-pocket copaymem 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 con-esponding copaymenr, YOll will only be responsible fur the lower amount. . Your copayments for covered prescription drugs are made on a per prescription or refiU basis and will not change ifHumana receives any reo'Ospective volume discounts or prescription drug rebates. There are no claim torms to file if you use a participating pharmacy and present your membership card with each prescription. Nonparticipating pharmacy coverage * YOll may also purchase prescribed medications from a nonparticipating pharmacy.You will be required to pay for your prescriptions according to the following rule. . You pay 100 percent of the dispensing pharmacy's charges. You file a claim torm with Humana (address is on the back of ID card). - Claim is paid at 70 percent of the dispensing pharmacy's charges. after they are first reduced by the applicable copaymem. . Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change ifHumana recei"lr-cs any retrospective volume discounts or prescription drug rebates. * In Georgia. the nonparticipating benefits are paid the same as the participating benefits. per st::lte regulation. Coverage specifics GN-12140-HH 5/03 Your coverage includes the tollowi.l1g: . A 30-day supply or the amount prescribed. whichever is less. for each pl-escription or refill. . Contraceptives. . Certain self-administered injectable drugs and related supplies approved by Humana. . Certain dnlg5, medicines or medications that, under tederal or st::lte law; may be dispensed only by prescription from a physician.