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articipating pharmacy coverage Your pharmacy coverage includes a three -tier copayment benefit. This means that when you present your membership card at a participating pharmacy, you will be required to make a copayment for your prescriptions based on the type of medication you purchase: • For a generic drug on the formulary, you will make a $5 copayment for a maximum 30 -day supply. • For a brand -name drug on the formulary, when a generic equivalent is not available, you will make a $15 copayment for a maximum 30 -day supply.* • For a drug that is not on the formulary and a generic equivalent is not available, you will make a $30 copayment for a maximum 30 -day supply.* There are no claim forms to file if you present your membership card with each prescription. Nonparticipating pharmacy coverage You may also purchase prescribed medications from a nonparticipating pharmacy.You will be required to pay for your iou iptions according to the following rule: pay 100 percent of the actual charges. - You file a claim form with Humana (address is on the back of ID card). - Claim is paid at 70 percent of the actual charges, after they are first reduced by the applicable copayment and any required difference in the cost between a brand - name medication and a generic medication. Coverage specifics Your coverage includes the following: • A 30 -day supply or the amount prescribed, whichever is less • Oral contraceptives • Self - administered injectable drugs approved by Humana will be paid at the applicable copayment. • Drugs, medicines or medications that under federal or state law may be dispensed only by prescription from a physician Formulary The Humana formulary is a comprehensive list that includes more than 850 brand -name and generic drug products that are approved by Humana and are available for use by members as a medication covered by their health care plan. It was developed and is maintained by a medical committee comprised of physicians and pharmacists. The formulary consists of medications chosen for their safety, effectiveness and affordability. If you purchase a prescribed medication that is not included on the formulary, you will pay the applicable copayment. Information about the Humana drug formulary is available to members by contacting a customer service representative at 1- 800- 4HUMANA (1- 800 - 448 - 6262). For a complete listing of participating pharmacies, please refer to your participating provider directory. fv z 1l order beg ie For your convenience, you may receive a maximum 90 -day supply of a prescribed maintenance medication for the cost of three applicable copayments per maximum 90 -day supply:* $15 generic /$45 brand /$90 non - formulary Please refer to the mail order brochure for a more detailed description of mail order benefits. 0 an available, generic medications will be used to fill your prescriptions. If you prefer or your physician prefers a brand -name medication when its generic lent is available, you must pay 100 percent of the difference in cost between the brand -name medication and generic as well as the applicable generic copayment. If no generic equivalent is available, you will receive the brand -name prescription for the applicable copayment. FL- 65891 -HH 3/99 Offered and Underwritten by Humana Insurance Company of Florida, Inc. ©1999 Humana Inc. All group sizes (continued on back)