FÓSFORO Y POTASIO

When you are being treated for an illness or accident, your Physician may pre­ scribe certain drugs or medicines as part of your treatment. Your coverage includes benefits for drugs and supplies which are self‐administered. This sec­ tion of your benefit booklet explains which drugs and supplies are covered and the benefits that are available for them. Benefits will be provided only if such drugs and supplies are Medically Necessary.

Although you can go to the Pharmacy of your choice, your benefit for drugs and supplies will be greater when you purchase them from a Participating Pre­ scription Drug Provider. You can visit the Claim Administrator's Web site at

www.bcbsil.com for a list of Participating Prescription Drug Providers. The Pharmacies that are Participating Prescription Drug providers may change from time to time. You should check with your Pharmacy before purchasing drugs or supplies to make certain of its participation status.

The benefits of this section are subject to all of the terms and conditions of this benefit booklet. Please refer to the DEFINITIONS, ELIGIBILITY and EX­ CLUSIONS sections of this benefit booklet for additional information regarding any limitations and/or special conditions pertaining to your benefits. For purposes of this Benefit Section only, the definition of Eligible Charge shall read as follows:

ELIGIBLE CHARGE...means (a) in the case of a Provider which has a written agreement with the Claim Administrator or the entity chosen by Blue Cross and Blue Shield to administer its prescription drug program to provide Covered Services to you at the time you receive the Covered Ser­ vices, such Provider's Claim Charge for Covered Services and (b) in the case of a Provider which does not have a written agreement with a Blue Cross and Blue Shield Plan or the entity chosen by the Claim Administrator to provide services to you at the time you receive Covered Services, either of the following charges for Covered Services:

(i) the charge which the particular Prescription Drug Provider usually charges for Covered Services, or

(ii) the agreed upon cost between Participating Prescription Drug Pro­ viders and a Blue Cross and Blue Shield Plan or the entity chosen by the Claim Administrator to administer its prescription drug pro­ gram, whichever is lower.

Additionally, the following definition(s) shall apply to this Benefit Section: FORMULARY...means a brand name drug or brand name diabetic supply that has been designated as a preferred drug or supply by the Claim Administrator.

SPECIALTY DRUGS...means prescription drugs generally prescribed for use in limited patient populations or diseases. These drugs are typically in­ jected or infused, but may also include high cost oral medications. In addition, patient support and/or education may be required for these drugs.

The list of Specialty Drugs is subject to change. You should refer to the for­ mulary list, contact your Pharmacy or refer to the Claim Administrator's Web site (www.bcbsil.com) to determine which drugs are Specialty Drugs.

COVERED SERVICES

The drugs and supplies for which benefits are available under this Benefit Sec­ tion are:

S drugs which are self‐administered that require, by federal law, a written prescription;

S self‐injectable insulin and insulin syringes;

S diabetic supplies, as follows: test strips, glucagon emergency kits and lancets.

Benefits for these drugs will be provided when:

S you have been given a written prescription for them by your Physician, Dentist, Optometrist or Podiatrist and

S you purchase the drugs from a Pharmacy or from a Physician, Dentist,

Optometrist or Podiatrist who regularly dispenses drugs, and

S the drugs are self‐administered. Benefits will not be provided for:

S drugs used for cosmetic purposes (including, but not limited to, Retin‐A/ Tretinoin and Minoxidil/Rogaine);

S drugs which are not self‐administered;

S any devices or appliances except as specifically mentioned above;

S any charges that you may incur for the drugs being administered to you. In addition, benefits will not be provided for any refills if the prescription is more than one year old.

One prescription means up to a 34 consecutive day supply of a drug. Certain drugs may be limited to less than a 34 consecutive day supply. However, for certain maintenance type drugs, larger quantities may be obtained through the Home Delivery Prescription Drug Program. For information on these drugs, contact your Participating Prescription Drug Provider or the Claim Adminis­ trator's office. Benefits for prescription inhalants will not be restricted on the number of days before an inhaler refill may be obtained.

Benefit Payment for Prescription Drugs

The benefits you receive and the Copayment amount you pay will differ de­ pending upon the type of drugs purchased and whether they are obtained from a Participating Prescription Drug Provider.

When you obtain drugs from a Participating Prescription Drug Provider, you must pay a Copayment amount of:

S $30for each prescription - for Formulary brand name drugs.

S $50for each prescription - for non‐Formulary brand name drugs. When you obtain diabetic supplies from a Participating Prescription Drug Pro­ vider, you must pay the Formulary brand name Copayment amount described above for each prescription. Benefits will be provided for the remaining Eligi­ ble Charge.

Benefits for lancets and lancet devices will be provided differently than dia­ betic supplies. There will be no cost to you for lancets and lancet devices. When you obtain drugs or diabetic supplies from a non‐Participating Prescrip­ tion Drug Provider (other than a Participating Prescription Drug Provider), 75% of the Eligible Charge will be paid minus the Copayment amount.

Home Delivery Prescription Drug Program

In addition to the benefits described in this Benefit Section, your coverage in­ cludes benefits for maintenance type drugs and oral contraceptives obtained through the Home Delivery Prescription Drug Program. For information about this program, contact your employer or Claim Administrator.

When you obtain drugs through the Home Delivery Prescription Drug Pro­ gram, you must pay a Copayment amount of:

S $10for each prescription - for generic drugs.

S $60for each prescription - for Formulary brand name drugs.

S $100for each prescription - for non‐Formulary brand name drugs. When you obtain diabetic supplies from a Participating Prescription Drug Pro­ vider, you must pay the Formulary brand name Copayment amount described above for each prescription. Benefits will be provided for the remaining Eligi­ ble Charge.

Benefits for lancets and lancet devices will be provided differently than dia­ betic supplies. There will be no cost to you for lancets and lancet devices.

BENEFITS FOR MEDICARE ELIGIBLE