PRESCRIPTION DRUG EXPENSE INSURANCE

This plan pays benefits for covered drugs prescribed by a doctor. What we pay and the terms of payment are explained below.

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Covered Drugs

This plan covers: (a) legend drugs; (b) compound drugs which include at least one legend drug; (c) injectable insulin; and (d) other drugs which, under applicable state law, may only be dispensed when prescribed by a doctor.

This plan only pays benefits for covered drugs which are: (a) prescribed by a doctor (except for insulin); (b) dispensed by a licensed pharmacist or by a hospital pharmacy for take-home use; (c) needed to treat a sickness or injury, and (d) accepted as safe and effective by the health community.

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DISPENSING LIMITS

Each time a covered drug is dispensed, we will pay a benefit for an amount not exceeding the greater of: (a) a 34 day supply, when used as prescribed; or (b) a 100 unit dose, when used as prescribed.

But what we pay is based on all the terms of this plan. See the "Exclusions" for drugs we exclude.

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BENEFIT PROVISIONS

Cash Deductible
A covered person must pay an out-of-pocket cash deductible for each covered drug each time it is dispensed. This prescription drug deductible must be paid before this plan pays any benefit for that drug. The deductible amount for each prescription or refill is: $10.00 .

After the deductible is paid, we will pay the covered charge in excess of the deductible for each covered drug dispensed while the covered person is insured. Of course, what we pay is subject to all the terms of this plan.

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EXTENDED BENEFIT

If a covered person is totally disabled and under a doctor's care when his insurance ends, we will extend his prescription drug expense insurance, in accordance with the Extended Benefits provision under the Major Medical portion of this plan, but not for more than three months. There is no premium charged for the extended prescription drug insurance coverage. But, the covered person will have to pay the cash deductible for each prescription.

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EMPLOYER LIABILITY

If a covered person's insurance ends for any reason, the employer will be liable to us for any benefits paid to such previously covered person after his insurance ends, except as described in the Extended Benefit provision.

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EXCLUSIONS

We won't pay for any of the following:

Administering a drug.

Drugs labeled "Caution - limited by Federal Law to investigational use", or experimental drugs.

Drugs, except injectable insulin, which can be obtained legally without a doctor's prescription.

Any therapeutic device or appliance. This includes diabetic test materials, hypodermic needles, syringes, support garments and other non-medical substances, regardless of their intended use.

Immunization agents, biological sera, blood or blood pla:sma, or vitamins (other than legend vitamins).

Drugs needed due to conditions caused, directly or indirectly, by a covered person taking part in a riot or other civil disorder; or the covered person taking part in the commission of a felony.

Drugs needed due to conditions caused, directly or indirectly, by declared or undeclared war or act of war.

Drugs dispensed to a covered person while on active duty in any armed force.

Drugs for which there is no charge. This usually means drugs furnished by the covered person's employer, labor union or similar group, in its medical department or clinic; a hospital or clinic owned or run by any government body; or any public program, except Medicaid, paid for or sponsored by any government body. But if a charge is made and we are legally required to pay it, we will.

Drugs dispensed to, or taken by, a covered person while confined to a hospital, an extended care center or a drug abuse, alcohol abuse or mental health center or any similar facility.

Any drugs which are paid for, in whole or in part, by another group health coverage or plan.

Drugs needed due to an on-the-job or job-related injury, or conditions for which benefits are payable by Worker's Compensation or similar laws.

Refills of a prescription in excess of the number of refills ordered by the doctor.

A refill dispensed more than one year from the date of the doctor's order.

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