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<br />Mail-order <br />benefit <br /> <br />e <br /> <br />e <br /> <br />For your convenience. you may receive a maximum 90-day supply per prescription or refill through the <br />mai.l (maximum 30-day supply for self-administered injeccable drugs). The same requirements apply <br />when purchasing medications through a participating mail-order pharmacy as apply when purchasing in <br />person at a pharmacy. Members can call Customer Service or visit 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 drugs, medicines. medications and supplies specified by Humana. This list <br />identifies drugs as Level One, Level Two, Level Three or Level Four and indicates applicable dispensing <br />limits and/or any prior authorization requirements. (This list is subject to change,) <br />. Copayment: the amoul1t to be paid by the member coward the COSt of each separate prescription or refill <br />of a covered drug when dispensed by a pharmacy. <br />. Nonparticipating pharmacy: a pharmacy which has not been designated by Humana as a <br />participating pharmacy. <br />. Participating pharmacy: a pharmal:y which has entered into an agreement with Humana or which has <br />been designared by HU111,111a to provide services to all covered persons. Participating pharmacy designation <br />by Hlunana may be limited to specified services. <br /> <br />Limitations and <br />exclusions <br /> <br />{ <br />"' <br /> <br />GN-12140-HH 5/03 <br /> <br />Unless specifically stated otherwise, no coverage is provided for the following: <br />. Any portion of a prescription or refill that exceeds a 30-day supply for a medication - 90-&y 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 from the cL'lte of the original order <br />. The administration of a covered medication <br />. Immunizing agents or biological serums or allergy e:-..'"rnlcts (may be covered under the medical plan) <br />. Infertility drugs (except where required b)' law) <br />. Drug delivery implants <br />. Any drug, medicine or medication labeled "Caution -limited by federal law to investigational use" or any <br />experime.ncal drug, medicine or medication, even though a charge is, or may be. made to the member <br />. Any costs related to the mailing, sending or delivery of prescription drugs <br />. Any drug used for weight concrol (except where required by law) <br />. Any drug prescribed for a nOJlcovered sickness or injury <br />. Abortifacients (drugs used to induce abortions) <br />. Any drug prescribed for impOtence and/or sexual dysfimction, e.g. Viagra <br />. Injectable drugs. including but not limited to immunizing agents, biological sera, blood, blood plasma or <br />self-adm.inistered injectable dl"Ugs not approved by Humana <br />. Dietary supplements, except for amino acid mod.ified preparations and low-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 />RJL~- <br /> <br />Insured by Humana Health Insurance Company of Florida, Inc., Humana Insurance Company. <br />Human3 Health Plan, Inc., or Humana Insurance of Puerto Rico, Inc. <br /> <br />@2003 Humana Inc. <br /> <br />HWl1anaPPO <br />