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.' I Mail-order benefit e e For YOw' convenience, you may receive a rn.:oomum 90-day supply per prescription or refill through the mail (nm..-imum 3D-day supply for self-administered injectable drugs). The same requirements apply when purchasing medications through a participating mail-order pharmacy as apply when purchasing in person at a pharmacy, Members can call Customer Service or v;sit our Web site for more information, including mail-order forms. Definition of terms . Drug List: a list of prescription drugs, medicines. medications and supplies specified by Humana. This list identifies drugs as Level One, Level Two, Level Three or Level Four and indicates applicable dispensing limits and/or any prior authorization requirements. (This list is subject to change.) . Copayment: the amount to be paid by the member to\vard the cost of each separate prescription or refill of a covered drug when dispensed by a pharmacy. . Nonparticipating pharmacy: a pharmacy which has not been designated by Humana as a participating pharmacy. . Participating pharmacy: a pharmacy which has entered into an agreement with Humana or which has been designated by Humana to provide services to all covered persons. Participating pharmacy designation by Humana may be limited to specified services. Limitations and exclusions C' Unless specifically stated otherwise, no coverage is provided for the following: . Any portion of a prescription or refill that exceeds a 30-day supply for a medication - 90-day supply for a prescription or refill (30-day supply for self-administered injecr.1hles) purchased through mail order. . Prescription refills in excess of the number specified by the physician's original order or dispensed mOI1~ than one year from the date of the original order . The administration of a covered medication . lm111wlizing agents or biological sej-um.~ or allergy e:l\.."tracts (may be covered under the medical plan) . Infertility drugs (except where required by law) . Drug delivery implants . Any drug, medicine or medication labeled "Caution - limited by federal law to investigational use" or any e"."perimental drug, medicine. or medication, even though a charge is, or may be, made to the member . Any COSts related to the mailing, sending or delivery of prescription drugs . Any drug used for weight control (except where required by law) . Any drug prescribed for a noncovered sickness or injury . Abormacients (drugs used to induce abortions) . Any drug prescribed for impotence and/or sexual dysfunction, e.g.Viagra . Injectable drugs. including but not limited to inununizing agents, biological sera, blood, blood plasma or self-administered injectable drugs not approved by Humana . Dietary supplements, except for amino acid modified preparations and low-protein modified food products necessary tor the treatment of inherited metabolic diseases. This is only a partial list of limitations and exclusions. Please refer to the Certificate of Coverage/Insurance for complete details regarding prescription drug coverage. ~ l!2.~_ ....~- Insured by Humana Health Insura.nce Company of Florida, Inc., Humana rnsurance Company, Humana. Health Plan, rnc., or Humana rnsurance of Puerto Rico, rnc, GN-12140-HUi 5/03 ~2003 Humana Inc. HumanaPPO