Sistema de aportes 1 Abonado y fertilización

Outpatient Prescription Drugs Benefits

Prescribed drugs, medicines and supplies purchased on an outpatient basis are covered provided they: a) can be lawfully obtained only with the written prescription of a Physician or dentist; b) are purchased by Covered Persons on an outpatient basis; c) are covered under the Group Policy; and d) do not exceed the maximum daily supply shown in the Schedule of Coverage, except that in no case may the supply be larger than that normally prescribed by a Physician or dentist.

Percentage Payable and Copayment: See the Schedule of Coverage, or Rider, if any, for the Copayment or Coinsurance per prescription for Generic Drugs or for Brand Name Drugs.

Limitations: A 90-day supply dispensing limitation. Benefits are subject to the Copayment, coinsurance, deductibles and Limitations and Exclusions (Please refer to Your Schedule of Coverage). The 90-day supply dispensing limitation does not apply to birth control pills. Birth control pills are subject to a 6 month dispensing limitation. Please refer to Your Schedule of Coverage for the dispensing limitation, if any, of specific drugs including birth control pills.

Home Delivery Service

A Covered Person may use the Home Delivery Service if the Covered Person takes maintenance medications to treat an acute or chronic health condition, such as high blood pressure, ulcers or diabetes. Benefits are subject to any limitations, Copayments, coinsurance, and the Deductibles shown in the Schedule of Coverage.

There is no shipping charge and no additional fees for home delivery prescriptions, unless You request special handling, such as overnight delivery.

You can order prescriptions for home delivery three ways:

1) Order Your prescription online at www.ScripPharmacy.com. Online prescription orders must be paid for in advance by credit card.

2) Call the ScripPharmacy 24-hour refill line at 800-926-2455 , 711 TTY. Prescription orders must be paid for in advance by credit card.

SAMPLE

3) Fill out and send in a ScripPharmacy patient profile and home delivery form. When You use this method of ordering, You can pay by check or credit card.

For more information and a current ScripPharmacy home delivery brochure, call our Pharmacy Administrator, MedImpact at (800) 788-2949 , 711 TTY.

Keep in mind that not all drugs are available through the home delivery service. Examples of drugs that cannot be mailed include:

• Controlled substances as determined by state and/or federal regulations; • Medications that require special handling;

• Medications administered by or requiring observation by medical professionals; and • Medications affected by temperature.

Payments and reimbursement for drugs obtained through the home delivery service are substantially the same as for drugs obtained at Participating and non-Participating Provider pharmacies.

Direct Reimbursement

When You order a prescription through the home delivery service, You must pay the full cost of the drug and submit a claim to MedImpact for reimbursement. When a Covered Person fills a prescription, he may obtain reimbursement by submitting a claim and proof of loss. Benefits are subject to any limitations and to any Deductible, Coinsurance and Copayment, shown in the Schedule of Coverage.

Drugs Covered

Covered Charges for outpatient prescription drugs are limited to charges from a licensed pharmacy for: 1) A prescription legend drug for which a written prescription is required;

2) Prescribed drug or device approved by the United States Federal Drug Administration (FDA); 3) Compounded medication of which at least one ingredient is a legend drug;

4) Prescription inhalants required to enable persons to breathe when suffering from asthma or other life- threatening bronchial ailments;

5) Prescription contraceptives are covered under Your Preventive Care benefits; 6) Coverage of off-label use of covered prescription drugs.

7) Prescription drugs and prescribed over the counter drugs for smoking cessation including aids are covered under Your Preventive Care benefits.

8) Time-released drugs, limited to implantable or injectable drugs no refund is given if the implant is removed).

9) Self-administered Injectable Medications. Coverage for Self-administered Injectable medications must meet the following criteria:

a) does not require administration by medical personnel; b) administration does not require observation;

c) patient's tolerance and response to the drug does not need to be tested, or has already been satisfactorily tested; and

d) prescribed for self-administration by the patient at home.

Self-administered Injectable Medications must be written on a prescription, filled by a pharmacy, and self- administered by the patient or caregiver at home (not administered by providers in the medical offices). Drugs Not Covered

The following items are excluded from Outpatient Prescription Drug coverage in addition to those set forth in the General Limitations and Exclusions section:

1) Administration of a drug or medicine.

2) Any drug or medicine administered as Necessary Services and Supplies. (See the General Definitions section.)

3) Supplies, drugs, medications, injections or intravenous therapies: a) provided at a hospital; or

SAMPLE

GENERAL BENEFITS

b) provided in connection with any home care benefit.

4) Drugs that do not require a prescription by law, except those drugs required by state or federal law. 5) Vitamins and other dietary supplements.

6) Any medication whose label is required to bear the legend “Caution: federal law prohibits dispensing without a prescription”; except experimental drugs that are used to treat cancer if one or more of the following conditions is met:

a) The drug is recognized for treatment of the Covered Person’s particular type of cancer in the United States Pharmacopoeia Drug Information, The American Medical Association Drug Evaluations or The American Hospital Formulary Service Drug Information publication; or

b) The drug is recommended for treatment of the Covered Person’s particular type of cancer and has been found to be safe and effective in formal clinical studies, the results of which have been published in either the United States or Great Britain.

7) Drugs labeled "caution - limited by federal law to investigational use", or experimental drugs, even though a charge is made to the Insured Employee or Insured Dependent. Except experimental drugs that are used to treat cancer if one or more of the following conditions is met:

a) The drug is recognized for treatment of the Covered Person’s particular type of cancer in the United States Pharmacopoeia Drug Information, The American Medical Association Drug Evaluations or The American Hospital Formulary Service Drug Information publication; or

b) The drug is recommended for treatment of the Covered Person’s particular type of cancer and has been found to be safe and effective in formal clinical studies, the results of which have been published in either the United States or Great Britain;

8) Therapeutic or other prosthetic devices, appliances, supports, and other non-medical appliances. 9) Biological serums.

10) Immunization agents.

11) Refills in excess of the number specified by the Physician or refills dispensed after one year from the Physician's order.

12) Allergens or allergy serums.

13) Drugs when used for cosmetic purposes, including Ioniten (Minoxidil) compounded for hair growth and Tretinon (Retin A).

14) DESI drugs: drugs determined by the Food and Drug Association as lacking substantial evidence of effectiveness.

15) Growth hormones and all synthetic analogs. 16) Androgens and anabolic steroids.

17) Experimental Drugs and Medicines, except experimental drugs that are used to treat cancer if one or more of the following conditions is met:

a) The drug is recognized for treatment of the Covered Person’s particular type of cancer in the United States Pharmacopoeia Drug Information, The American Medical Association Drug Evaluations or The American Hospital Formulary Service Drug Information publication; or

b) The drug is recommended for treatment of the Covered Person’s particular type of cancer and has been found to be safe and effective in formal clinical studies, the results of which have been published in either the United States or Great Britain;

NOTE: Unless an exception is made by KPIC or its designee, drugs not approved by the Food and Drug administration and in general use as of March 1 of the year immediately preceding the year in which this Certificate became effective or was last renewed are not covered.