Prescription Drugs and Medicines Benefit

The Plan provides benefits for Covered Prescription Expenses in excess of the Deductible and Co-payment amounts.  These benefits are provided through an independent Prescription Benefit Manager.

Covered Prescription Expenses

Covered Prescription Expenses are necessary and reasonable expenses incurred for drugs and medicines which require a doctor’s prescription, and injectible insulin prescribed by a physician, which are necessary in the treatment of an illness.

Deductible and Co-Payment Amounts

The Deductible amount is an expense which you or your dependents are required to pay before you are entitled to prescription benefits.  The Co-Payment is the amount you must pay for each prescription before a benefit is payable by the Plan.  The calendar year deductible and the co-payment factors are shown in the Schedule of Benefits.

Limitations

The Plan does not provide coverage for any of the following types of expenses:

• Drugs or medicines lawfully obtained without a doctor’s prescription
• Refills of any prescription in excess of the number of refills specified by the doctor, or any drugs or medicines dispensed more than one year following the date of the doctor’s prescription order
• Any quantity of drugs or medicines dispensed which exceed a thirty-four (34) day supply or one hundred (100) unit doses, whichever is greater, when taken in accordance with the directions of the prescriber, except if provided under the mail service program
• Prescription drugs which may be properly received without charge under local, state or federal programs
• Drugs labeled “Caution – limited by federal law to investigational use”, or experimental drugs, even though a charge is made to the Covered Individual
• Drugs prescribed for indications not approved by the Food and Drug Administration (FDA)
• Drugs or medicines in whole or in part, to be taken by, or administered to a Covered Individual during confinement in a hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home or similar institution
• Therapeutic devices or appliances, including hypodermic needles, syringes, support garments and other non-medical substance, regardless of there intended use
• Any charges for immunization agents, biological sera, blood or blood plasma, including the administration thereof
• Any charges for contraceptives, contraceptive materials, contraceptive devices or infertility medication
• A.D.D. / Narcolepsy medications for individuals twenty-four (24) years of age and older
• Anabolic steroids
• Anti-wrinkle agents (i.e.: Renova)
• Any drugs used for cosmetic purposes
• Dermatologicals and hair stimulants
• Erectile dysfunciton medications
• Fluoride supplements
• Growth hormones
• Hemantinics
• Immunization agents, blood and blood plasma
• Impotence medications
• Infertility medications
• Interferon (Avonex)
• Isotretinoin (Accutane)
• Levonorgestrel (Norplant)
• Mineral and nutrient supplements
• Non-legend drugs other than insulin
• Pigmenting and depigmenting agents
• Tretinoin topical (i.e.: Retin-A)
• Vitamins, singly or in combination

The following types of expenses require a 100% co-payment from the participant:

• Non-sedating antihistamines

o        Allegra, Clarinex, Zyrtec and any similar types

• Proton Pump Inhibitors

o        Aciphex, Nexium, Omeprazole, Prevacid, Prilosec, Protonix and any similar types

Important Notice:  Although the prescription drugs and medicines outlined in the Limitations may appear in the Prescription Benefit Managers listings of “Preferred Drugs” or “Primary Drugs”, they are specifically excluded from coverage by the Plan.