PRESCRIPTION CARD PROGRAM

WHAT IS COVERED:

Insulin and insulin syringes on prescription only.
Any legend drug or any drug that requires a prescription by state or federal law.

- except -

Oral contraceptives, regardless of intended use
Medical devices, except insulin syringes
Smoking deterrents
Rogaine
Anorexiants (diet control drugs)
All over the counter medication (OTC drugs)
Contraceptive devices, IUDs and diaphragms
Fertility drugs
Retin-A, if over age 26
Growth hormone
Allergy serums and extracts
Experimental drugs or drugs under investigational use
Schedule II Narcotics not available by Mail Order (available by prescription at store only)

NOTE: All or some of the above may be covered by your major medical or
employer sponsored 125 flexible spending account. See your Plan Administrator.

- and - Store issued prescriptions will be limited to one (1) 21-30 day supply. For refills and longer supplies (except narcotics) mail order is to be used.

EMPLOYER SPONSORED AND PAID

Rate based on number of employees eligible.
An eligible employee is employed 25 or more hours per week and not covered elsewhere for similar prescription coverage.
Store Script:
$4.00 copay - Generic Script

- and -

$4.00 copay - Name Brand only, if no acceptable generic equivalent is available, regardless of Doctor's dispense as written (DAW).

- except -

Patient may elect Name Brand over Generic by paying the difference in cost between Generic and Name Brand selected, plus copay, at point of sale. Maximum reimbursement $1000.00 per plan member per plan year.

Mail Order Script:
$2.00 copay - Generic Script
- and - $2.00 copay - Name Brand only, if no acceptable generic equivalent is available, regardless of Doctor's dispense as written (DAW).

- except -
Patient may elect Name Brand over Generic by paying the difference in the cost between Generic and Name Brand mail order cost, plus copay. Maximum reimbursement $1000.00 per plan member per plan year.

EMPLOYER OR ASSOCIATION SPONSORED VOLUNTARY PAYROLL DEDUCT OR 125:

Rate based on number of employees actually enrolled * $10.00 copay - Generic Script
- and -
$10.00 copay - Name Brand only, if no acceptable generic equivalent is available. regardless of Doctor's dispense as written (DAW).
- except -
Patient may elect Name Brand over Generic by paying the difference in cost between Generic and Name Brand selected, plus copay, at point of sale. Maximum reimbursement $750.00 per plan member per plan year.

* Mail Order Script:
$4.00 copay - Generic Script
- and -
$4.00 copay - Name Brand only, if no acceptable generic equivalent is available, regardless of Doctor's dispense as written (DAW).

- except -
Patient may elect Name Brand over Generic by paying the difference in the cost between Generic and Name Brand mail order cost, plus copay. Maximum reimbursement $750.00 per plan member per plan year.