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<br />Mail-order <br />benefit <br /> <br />For your convenience, you may receive a maximum 90-day supply per prescription or refill through the <br />mail (maximum 3D-day supply for self-administered injectable 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 Serv-ice or visit our Web site for more information, <br />including mail-order forms. <br /> <br />Definition <br />of terms <br /> <br />. Drug List: a list of prescription drugs, medicines. medications and supplies specitied by Humana. This list <br />identifies drugs as Level One, Level Two, Level Three or Level Four and indicates applicable dispensing <br />limits andlor any prior authorization requirements. (This list is subject to change.) <br />. Copayrnent: the amount to be paid by the member tov.;ard 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 pharmacy which has entered into an agreement with Humana or which has <br />been designated by H= to pro"\-ide services to all covered persons. Participating pharmacy designation <br />by Humana may be limitea to specified sen-ices. <br /> <br />Limitations and <br />exclusions <br /> <br />GN-12140-HH 5/03 <br /> <br />Unless specifically stated othen,,-ise, no coverage is provided for the follo"\'.--ing: <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 (30-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 date of the original order . <br />. The administration of a covered medication <br />. Immunizing agents or biological serums or allergy eA"tracts (may be covered under the medical plan) <br />. Infertility drugs (e.\:cept 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 />experirnental 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 control (except where required by law) <br />. Any drug prescribed for a noncovered sickness or injury <br />. Abortifacients (drugs used to induce abortions) <br />. Any drug prescribed for in1pOtence andlor sex-ual dysfunction, e.g.Via",crra <br />. Injectable drugs. including but not limited to immunizing agents, biological sera, blood, blood plasma or <br />self-administered injectable drugs not approved by Humana <br />. Dietary supplements, except for amino acid modified preparations and low-protein modified food <br />products necessary for the treatment of inherited metabolic diseases. <br /> <br />'Ib.is is only a partial list of limitations and exclusions. Please refer to the Certificate of <br />CoveragelInsurance for complete details regarding prescription drug coverage. <br /> <br />" l!2-~_ <br /> <br />Insured by Humana Health Insurance Company of Florida, Inc., Humana Insurance Company. <br />Hum.ma Health Plan, Inc.. 01' Humana Insurance of Pueno Rico. Ine. <br /> <br />(g2003 Humana Ine. <br /> <br />HwnanaPPO <br />