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e e "~o~:i'67~lIb?'ii~~~~~~~~~(f.~~WP;.~-;'-B7;;~i:::? Level One:- $1 0, ~~Y~~:}W~~~;;~:~ri-~~~~l ~~re~f/~~,~;{~vfr~~ur"~;~~;%;:~::.::':._ . .;". '. ..:~' <. - .~. .' : "'~;.i: I ; '{" ~.. ~}~~~~~;;F"~.:1~I~).m1TI1~ff~~:-:n..){iT{:~"TI5:~wf;~~*b:~~~~:;,r~~:~~;;j:~~~~:'w.}]fi;~~51!:'..~u..~ 1 I ;,.~' h..~ Jt'~'~~~~~:!rt!ht'~!ikTh?~~~~~~~~J!:;~~t~~1kt~$~;\-~H~~~"~Fi1id!!1~f ~1;~r~:t!iJ;'~J,ft~P\:~~~~ifj~ How the Rx4 structure works Covered prescription drugs are assigned to one of four difterent levels ""ith corresponding copaymenr amounts. The levels are organized as follo'''15: . Level One: lowest copaymellt for ]ow COSt generic and brand-name dl1.lgs. . Level Two: higher copayment for higher cost generic and br:l11d-name drugs. . Level Three: higher copaymem than Level Two for higher cost, mostly brand-name drugs that may have generic or brand-name alternatives on Levels One or Two. . Level Four: highest copayment for high-technology drugs (certain brand-name drugs, biotechnolog)' 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 su bject to dispensing limitations, based on age, gender, duration or q'uantity. Additionally, some Level Four cInlgs may need prior authorization in order to be covered. In these cases. your physician should contact Humana Clinica] Pharmacy Review at 1-800-555-CLIN (2546). Members can visit.Humana'sWeb site, www.humana.com.to obt.'lin information about their 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 eA-plain the Rx4 structure. For a complete listing of participating pharmacies, please refer to our Web site or your participating provider directof)~ 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 cw'rent assigned level of the drug. Drugs assigned to: Copayment per prescription or refill Leve] One: SlO Le"e1 Two: S25 Level Three: S50 Level Four: 25%* of the total required payment to the dispensing pharmacy per prescription or refill. * The total maximum out-of-pocket copayment 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 v.riJl only be responsible for 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 110 claim torms to file if you use a participating pharmacy and preseot YOllr membership card VI>ith each prescription. Nonparticipating pharmacy coverage* You may aL~o purchase prescribed medications trom 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 form with Humana (address is on the back ofID card). - Claim is paid at 70 percent of the dispensing pharrnacy's charges. after they are first reduced by the applicable copayment. . Your copayments for covered prescription dnJgs are made on a per prescription or refill basis and will nor challge ifHumana receives any retrospective volume discounts or prescription dnlg rebates. * In Georgia. the nonparticipating benefits are paid the same as the participating benefits, per state reguJation. Coverage specifics c GN-12140-HH 5/03 Your coverage includes the following: . A 30-day supply or the amount prescribed. whichever is less. for each prescription or refill. . Contraceptives. . Certain self-administered injectable drugs and related supplies approved by Humana. . Certain drugs, medicines or medications that, under tederal or st.'1te law, may be dispensed only by prescription from a physician.