Distinct Advantage – PPO Plan 3 – 2500(40)97 Attachment A Benefit Schedule This Plan does not include maternity coverage. Lifetime Maximum Benefit for all Covered Services: $2,000,000 of Eligible Medical Expenses (“EME”). Calendar Year Deductible (“CYD”): $2,500 per Insured and $5,000 per family. The CYD is a combined total of Plan and Non-Plan EME. The CYD does not accumulate toward the Calendar Year Coinsurance Maximum. Please read your SHL Agreement of Coverage to understand how EME payments to Providers are determined. Plan Providers have agreed to accept SHL’s Reimbursement Schedule as payment in full for Covered Services, less any applicable CYD, Copayments and/or Coinsurance due from the Insured. Coinsurance: After satisfying your CYD, your Coinsurance for most Plan Provider services is 10% of EME. Your Coinsurance for most Non-Plan Provider services is 30% of EME. (Please reference the following pages for specific Coinsurance responsibilities). Coinsurance Maximum: After satisfying your CYD, your Coinsurance is limited to a maximum of $2,500 of EME per Insured per Calendar Year ($5,000 per family) when using Plan Providers, and $5,000 of EME per Insured per Calendar Year ($10,000 per family) when using Non-Plan Providers. Form No. SHL-IndDAP-masBS-2005 Page 1 Important Note: You are responsible for all amounts exceeding the applicable benefit maximums, EME payments to Non-Plan Providers, and penalties for not complying with the Managed Care Program. Please reference the following pages for specific Coinsurance responsibilities. (NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3 Legal Documents In no event will the Coinsurance Maximum exceed $7,500 of EME per Insured per Calendar Year ($15,000 per family). The Coinsurance Maximum does not include Copayments, Prescription Drug Fees, or CYD. Benefit Schedule Covered Services and Limitations Prior Auth Required Plan Provider Benefits(1) Medical - Physician Services and Physician Consultations Non-Plan Provider Benefits(1) After CYD, SHL pays 70% of EME. Office Visit/Consultations Includes routine lab and x-ray services provided and billed by the Physician’s office. No Insured pays $40 per visit. Inpatient Visit/Consultations Yes After CYD, SHL pays 90% of EME. Preventive Healthcare Services Includes routine lab and x-ray services provided and billed by the Physician’s office. No Insured pays $40 per visit. Subject to the maximum benefit. After CYD, SHL pays 70% of EME. Subject to the maximum benefit. Laboratory Services - Outpatient Yes After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. Routine Radiological and NonRadiological Diagnostic Imaging Services - Outpatient Yes After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. Maximum benefit is $500 per Calendar Year. After CYD, SHL pays 70% of EME. Emergency Services Urgent Care Facility No Insured pays $55 per visit. Physician’s Services in Emergency Room No After CYD, SHL pays 90% of EME. Emergency Room Facility No After CYD, SHL pays 90% of EME. Hospital Admission – Emergency Stabilization Applies until patient is stabilized and safe for transfer as determined by the attending Physician. No After CYD, SHL pays 90% of EME. Maximum benefit for Medically Necessary but Non-Emergency Services received in an emergency room is 50% of EME. Form No. SHL-IndDAP-masBS-2005 Page 2 (NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3 Benefit Schedule Covered Services and Limitations Prior Auth Required Plan Provider Benefits(1) Non-Plan Provider Benefits(1) Ambulance Services Emergency – Ground Transport No After CYD, SHL pays 90% of EME per trip. After CYD, SHL pays 70% of EME per trip. Emergency – Air Transport No After CYD, SHL pays 50% of EME per trip. After CYD, SHL pays 50% of EME per trip. SHL Arranged Transfers Yes No charge per trip. No charge per trip. Inpatient Hospital Facility Services Elective and Emergency poststabilization admission. Yes After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. Outpatient Hospital Facility and Ambulatory Surgical Facility Services, includes Sterilization Yes After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. Inpatient Hospital Facility Yes After CYD, SHL pays 90% of EME. Outpatient Hospital Facility Yes After CYD, SHL pays 90% of EME. Physician’s Office (In addition to office visit Copayment and/or Coinsurance.) Yes Insured pays $40 per visit. Assistant Surgical Services Yes After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. Anesthesia Services Yes After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. Yes After CYD, SHL pays 50% of EME. Subject to the Maximum benefit. After CYD, SHL pays 50% of EME. Subject to the maximum benefit. Gastric Restrictive Surgical Services Physician Surgical Services The maximum lifetime benefit for all Gastric Restrictive Surgical Services is $5,000 per Insured. Form No. SHL-IndDAP-masBS-2005 Page 3 (NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3 Legal Documents After CYD, SHL pays 70% of EME. Inpatient and Outpatient Physician Surgical Services, includes Sterilization Benefit Schedule Covered Services and Limitations Prior Auth Required Plan Provider Benefits(1) Non-Plan Provider Benefits(1) Gastric Restrictive Surgical Services (continued) Complications The maximum lifetime benefit for all complications in connection with Gastric Restrictive Surgical Services is $5,000 per Insured. Yes Mastectomy Reconstructive Surgical Services Physician Surgical Services Yes Prosthetic Devices for Mastectomy Reconstruction – Unlimited. Yes After CYD, SHL 50 pays % of EME. Subject to the maximum benefit. After CYD, SHL pays 50% of EME. Subject to the maximum benefit. After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. After CYD, SHL pays 70% of EME. Oral Surgical Services Office Visit Yes Insured pays $40 per visit. Physician Surgical Services • Inpatient Hospital Facility Yes After CYD, SHL pays 90% of EME. • Yes After CYD, SHL pays 90% of EME. Inpatient Hospital Facility Services Yes After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. Physician Surgical Services Yes After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. Transportation, Lodging and Meals The maximum benefit per Insured per Transplant Benefit Period for transportation, lodging and meals is $10,000. The maximum daily limit for lodging and meals is $200. Yes After CYD, SHL pays 90% of EME. Subject to the maximum benefit. After CYD, SHL pays 70% of EME. Subject to the maximum benefit. Outpatient Hospital Facility Organ and Tissue Transplant Surgical Services Form No. SHL-IndDAP-masBS-2005 Page 4 (NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3 Benefit Schedule Covered Services and Limitations Prior Auth Required Plan Provider Benefits(1) Non-Plan Provider Benefits(1) Organ and Tissue Transplant Surgical Services (continued) Procurement The maximum benefit per Insured per Transplant Benefit Period for procurement of the organ/tissue is $15,000 of EME. Yes After CYD, SHL pays 90% of EME. Subject to the maximum benefit. After CYD, SHL pays 70% of EME. Subject to the maximum benefit. Retransplantation Services The 50% of EME for Retransplantation Services does not apply towards your Calendar Year Coinsurance maximum. Yes After CYD, SHL pays 50% of EME. Subject to the maximum benefit. After CYD, SHL pays 50% of EME. Subject to the maximum benefit. After CYD, SHL pays 90% of EME. Subject to the maximum benefit. After CYD, SHL pays 70% of EME. Subject to the Maximum benefit. The maximum lifetime benefit that will be paid for an Insured for all Covered Transplant Procedures combined is $100,000. Physician House Calls Yes Home Care Services Yes Private Duty Nurse Yes Maximum benefit is limited to $5,000 per Insured per Calendar Year. Hospice Care Services Inpatient Hospice Services Yes After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. Outpatient Hospice Services Yes After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. Inpatient Respite Services Limited to $1,500 per Insured per Calendar Year. Yes After CYD, SHL pays 90% of EME. Subject to the Maximum benefit. After CYD, SHL pays 70% of EME. Subject to the maximum benefit. Form No. SHL-IndDAP-masBS-2005 Page 5 (NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3 Legal Documents Home Healthcare Services Refer to your outpatient Prescription Drug Benefit Rider, if applicable, for your outpatient self-injectable covered drug benefit. Benefit Schedule Covered Services and Limitations Prior Auth Required Plan Provider Benefits(1) Non-Plan Provider Benefits(1) Hospice Care Services (continued) Outpatient Respite Services Limited to $1,000 per Insured per Calendar Year. Yes After CYD, SHL pays 90% of EME. Subject to the maximum benefit. After CYD, SHL pays 70% of EME. Subject to the maximum benefit. Bereavement Services Limited to five (5) group therapy sessions or $500 per Insured, whichever is less. Treatment must be completed within six (6) months of the date of death. Yes After CYD, SHL pays 90% of EME. Subject to the maximum benefit. After CYD, SHL pays 70% of EME. Subject to the maximum benefit. Skilled Nursing Facility Maximum benefit is $3,500 per Insured per Calendar Year. Yes After CYD, SHL pays 90% of EME. Subject to the maximum benefit. After CYD, SHL pays 70% of EME. Subject to the maximum benefit. Manual Manipulation (except for reduction of fractures or dislocation) Maximum benefit is $500 per Insured per Calendar Year and $5,000 per lifetime. Yes After CYD, SHL pays 90% of EME. Subject to the maximum benefit. After CYD, SHL pays 70% of EME. Subject to the Maximum benefit. After CYD, SHL pays 90% of EME. Subject to the maximum benefit. After CYD, SHL pays 70% of EME. Subject to the maximum benefit. Short-Term Rehabilitation Services Inpatient Hospital Facility or Skilled Nursing Facility Maximum benefit is $20,000 per Insured per Calendar Year. Yes Outpatient Hospital Facility Maximum benefit is $2,500 per Insured per Calendar Year. Yes Genetic Disease Testing Services Includes Inpatient, outpatient and independent laboratory services. Yes After CYD, SHL pays 50% of EME per test. After CYD, SHL pays 50% of EME per test. Infertility Office Visit Evaluation Please refer to Covered Services Copayments and/or Coinsurance amounts for any infertility procedures performed. Yes Insured pays $40 per visit. After CYD, SHL pays 70% of EME. Form No. SHL-IndDAP-masBS-2005 Page 6 (NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3 Benefit Schedule Covered Services and Limitations Medical Supplies Prior Auth Required Plan Provider Benefits(1) Non-Plan Provider Benefits(1) Yes After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. After CYD, SHL pays 90% of EME. After CYD, SHL pays 70% of EME. After CYD, SHL pays 50% of EME per test After CYD, SHL pays 90% of EME. Subject to the maximum benefit. After CYD, SHL Pays 50% of EME Per test After CYD, SHL pays 70% of EME. Subject to the Maximum benefit. Other Diagnostic and Therapeutic Services Yes Amniocentesis Yes Anti-cancer drug therapy, non-cancer related intravenous injection therapy or other Medically Necessary intravenous therapeutic services. Yes Dialysis Yes Other services such as: • complex diagnostic imaging (i.e., CAT scan, MRI); • complex neurological or psychiatric testing or therapeutic services; • pulmonary diagnostic services; • vascular diagnostic and therapeutic services. Yes Otologic Evaluations Yes Therapeutic Radiology Yes Positron Emission Tomography (PET) Scans Yes Prosthetics, Orthotic Devices and Durable Medical Equipment DME benefit includes rental or purchase at SHL’s option. Yes Legal Documents Allergy Testing/Serum Injections Lifetime maximum benefit per Insured is $10,000 for Prosthetics, Orthotics and Durable Medical Equipment combined. After CYD, SHL pays 70% of EME. Self-Management and Treatment of Diabetes Education and Training Form No. SHL-IndDAP-masBS-2005 No Page 7 Insured pays $40 per visit. (NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3 Benefit Schedule Covered Services and Limitations Prior Auth Required Plan Provider Benefits(1) Self-Management and Treatment of Diabetes (continued) Non-Plan Provider Benefits(1) After CYD, SHL pays 70% of EME. Supplies (except for Insulin Pump Supplies) No Insured pays $5 per therapeutic supply. • Yes Insured pays $40 per therapeutic supply. Equipment (except for Insulin Pumps) Yes Insured pays $20 per device. • Yes Insured pays $100 per device. Special Food Products and Enteral Formulas Special Food Products are limited to a maximum benefit of $2,500 per Insured per Calendar Year. Yes After CYD, SHL pays 90% of EME. See maximum benefit. After CYD, SHL pays 70% of EME. See maximum benefit. Temporomandibular Joint Treatment Maximum benefit is $2,500 per Insured per Calendar Year and $4,000 per lifetime. Yes After CYD, SHL pays 50% of EME. Subject to the maximum benefit. After CYD, SHL pays 50% of EME. Subject to the maximum benefit. After CYD, SHL pays 90% of EME. Subject to the maximum benefit. After CYD, SHL pays 70% of EME. Subject to the maximum benefit. Insulin Pump Supplies Insulin Pumps Mental Health Services Inpatient Hospital Facility Maximum benefit is thirty (30) days per Insured per Calendar Year. Outpatient Treatment • Group Therapy Limited to twenty (20) visits per Insured per Calendar Year. • Individual, Family and Partial Care Therapy** Limited to twenty (20) visits per Insured per Calendar Year. Yes Yes Yes Benefit maximum does not apply to visits for medication management. Form No. SHL-IndDAP-masBS-2005 Page 8 (NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3 Benefit Schedule Covered Services and Limitations Prior Auth Required Plan Provider Benefits(1) Non-Plan Provider Benefits(1) Mental Health Services (continued) ** Partial Care refers to a coordinated outpatient program of treatment that provides structured daytime, evening and/or weekend services for a minimum of four (4) hours per session as an alternative to Inpatient care. Severe Mental Illness Services Yes After CYD, SHL pays 90% of EME. Subject to the maximum benefit. Outpatient Hospital Facility Maximum benefit is forty (40) visits per Insured per Calendar Year for all outpatient services combined. Yes Insured pays $40 per visit. Subject to the maximum benefit. Legal Documents Inpatient Hospital Facility Maximum benefit is forty (40) days per Insured per Calendar Year. After CYD, SHL pays 70% of EME. Subject to the maximum benefit. Two (2) visits for partial or respite care,or a combination thereof, may be substituted for each (1) day of Inpatient hospitalization not used by the Insured. Benefit maximum does not apply to visits for medication management. Substance Abuse Services Inpatient Rehabilitation Maximum benefit is $9,000 per Insured per Calendar Year. Yes Outpatient Rehabilitation* • Group Therapy • Individual, Family and Partial Care Therapy** Yes After CYD, SHL pays 90% of EME. Subject to the maximum benefit. After CYD, SHL pays 70% of EME. Subject to the maximum benefit. *Rehabilitation counseling services for all group, individual, family and partial care therapy is limited to a maximum benefit of $2,500 per Insured per Calendar Year. Form No. SHL-IndDAP-masBS-2005 Page 9 (NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3 Benefit Schedule Prior Auth Required Plan Provider Benefits(1) Non-Plan Provider Benefits(1) Inpatient Detoxification (treatment for withdrawal) Yes After CYD, SHL pays 90% of EME. Subject to the maximum benefit. After CYD, SHL pays 70% of EME. Subject to the maximum benefit. Outpatient Detoxification Yes Covered Services and Limitations Substance Abuse Services (continued) Limited to a maximum benefit of $1,500 per Insured per Calendar Year. ** Partial Care refers to a coordinated outpatient program of treatment that provides structured daytime, evening and/or weekend services for a minimum of four (4) hours per session as an alternative to Inpatient care. Please read the SHL Agreement of Coverage to determine the governing contractual provisions, exclusions and limitations. Please note in addition to specified surgical Copayment and/or Coinsurance amounts, Insured is also responsible for all other applicable facility and professional Copayment and/or Coinsurance amounts as outlined in the Attachment A Benefit Schedule. Any and all amounts exceeding any stated maximum benefit amounts under the Plan do not accumulate to the calculation of the Calendar Year Coinsurance Maximum. (1) If Medically Necessary Covered Services are provided without Prior Authorization, benefits are reduced to 50% of what the Insured would have received with Prior Authorization. Form No. SHL-IndDAP-masBS-2005 Page 10 (NV 2005\Individual\IPPO\MasterForm#) 41NVSHLBE_DAP3 Distinct Advantage PPO 3-Tier Individual Prescription Drug Benefit Rider PLAN PHARMACY Tier I: Preferred Generic Covered Drugs Insured pays: $7.00 Preferred Generic Covered Drug Fee per Retail Plan Pharmacy Therapeutic Supply $14.00 Preferred Generic Covered Drug Fee per Mail Order Plan Pharmacy Maintenance Supply Insured pays: $35.00 Preferred Brand Name Covered Drug Fee without a Generic Covered Drug equivalent per Retail Plan Pharmacy Therapeutic Supply $70.00 Preferred Brand Name Covered Drug Fee per Mail Order Plan Pharmacy Maintenance Supply Tier III: Non-Preferred Generic or Brand Name Covered Drugs Insured pays: $55.00 Non-Preferred Generic or Brand Name Covered Drug Fee per Retail Plan Pharmacy Therapeutic Supply NON-PLAN PHARMACY SHL pays 70% of EME for Covered Drugs less the applicable Generic, Brand Name or Non-Preferred Drug Fee per Therapeutic Supply Form No. SHL-IPPO-3TierSIO-2004 Page 1 (NV 2003\SHL IPPO) 41NVSHLRI_RXDAP Legal Documents Tier II: Preferred Brand Name Covered Drugs without a Generic Covered Drug Equivalent Prescription Drug Rider This Prescription Drug Benefit Rider is issued in consideration of: (a) your election of coverage under this Rider, (b) your eligibility for the benefits described in this Rider, and (c) payment of any additional premium. • c) Tier III applies when: This Prescription Drug Benefit Rider, when attached to the Sierra Health and Life Insurance Company, Inc. (“SHL”) Individual PPO Agreement of Coverage (“AOC”) and Attachment A Benefit Schedule amends your coverage to include benefits for Covered Drugs. This coverage is subject to the applicable terms, conditions, limitations and exclusions contained in your SHL AOC and herein. SECTION 1. Obtaining Covered Drugs Plan Pharmacy Benefit Payments Benefits for Covered Drugs obtained at a Plan Pharmacy are subject to the following provisions as applicable: a) Tier I applies when: • a Preferred Generic Covered Drug is dispensed; and • any required Prior Authorization has been obtained. • The Insured will pay the Preferred Generic Drug Fee to the Plan Pharmacy for each Therapeutic Supply. b) Tier II applies when: • • a Preferred Brand Name Covered Drug is dispensed which has no Preferred Generic Drug equivalent; and any required Prior Authorization has been obtained. Form No. SHL-IPPO-3TierSIO-2004 a Non-Preferred Generic or Brand Name Covered Drug is dispensed; and • any required Prior Authorization has been obtained. • The Insured will pay the Non-Preferred Drug Fee to the Plan Pharmacy for each Therapeutic Supply. • A Generic Covered Drug will be dispensed when available, subject to the prescribing Provider’s “Dispense as written” requirements. 1.1 • d) Mandatory Generic benefit provision applies when: Benefits for Covered Drugs are payable under the terms of this Rider subject to the following conditions: • The Insured will pay the Preferred Brand Name Drug Fee to the Plan Pharmacy for each Therapeutic Supply. a Preferred Brand Name Covered Drug is dispensed and a Generic Covered Drug equivalent is available. The Insured will pay the Tier I Covered Drug Fee plus the difference between the EME of the Generic Covered Drug and the EME of the Brand Name Covered Drug to the Plan Pharmacy for each Therapeutic Supply. e) When a Maintenance Drug is dispensed through the Mail Order Plan Pharmacy, the applicable Mail Order Plan Pharmacy benefit tier will apply per Maintenance Supply. 1.2 Non-Plan Pharmacy Benefit Payments When a Covered Drug is dispensed by a Non-Plan Pharmacy, the Insured will pay to the Non-Plan Pharmacy at the time the drug is dispensed, the full cost of the Covered Drug subject to the following: a) In order that claims for Covered Drugs obtained at a Non-Plan Pharmacy be eligible for benefit payment, the Insured must complete and submit a claim form with the prescription label/receipt to SHL or its designee. b) Benefit payments are subject to the limitations and exclusions set forth in the SHL AOC and this Rider. All charges in excess of the EME after SHL pays the Non-Plan Pharmacy percentage shown less the applicable Page 2 (NV 2003\SHL IPPO) 41NVSHLRI_RXDAP Prescription Drug Rider Preferred Generic, Brand Name or Non-Preferred Covered Drug Fee will be paid by the Insured. without Prior Authorization, benefits are reduced to 50% of what the Insured would have received with Prior Authorization. 1. When a Preferred Generic or Brand Name Covered Drug is dispensed by a Non-Plan Pharmacy, the benefit payment will equal the Non-Plan Pharmacy percentage less the applicable Drug Fee. The Insured is responsible for the amounts exceeding SHL’s benefit payment. 2. When a Non-Preferred Covered Drug is dispensed by a Non-Plan Pharmacy, the benefit payment will equal the Non-Plan Pharmacy percentage of EME less the Non-Preferred Drug Fee. The Insured is responsible for the amounts exceeding SHL’s benefit payment. a) Benefits for a Maintenance Supply of Preferred Maintenance Drugs are available when dispensed by an SHL Mail Order Pharmacy for the applicable Mail Order Drug Fee(s) as shown on page 1, and any additional amounts subject to (a), (b) or (d) in Section 1.1. 2.6 Benefits for Prior Authorized Medically Necessary Compounds as defined herein are payable according to the Non-Preferred benefit tier. 2.7 Benefits for Non-Preferred Self-Injectable and Orphan Covered Drugs as defined herein are payable at 50% of EME. b) Information on how to obtain Mail Order Preferred Maintenance Drugs is provided in the Mail Order Brochure provided after enrollment in the Plan. SECTION 3. Exclusions SECTION 2. Limitations 2.1 Benefits for certain Medically Necessary Covered Drugs may require Prior Authorization from SHL including, but not limited to some medical supplies, outpatient immunosuppressive drugs, and Self-Injectable and Orphan Covered Drugs. If such Covered Drugs are provided Page 3 No benefits are payable for the following drugs, devices and supplies as well as for any complications resulting from their use except when prescribed in connection with the treatment of Diabetes: 3.1 Any drug, supply or device which can be purchased without a prescription, including those prescribed; (NV 2003\SHL IPPO) 41NVSHLRI_RXDAP Legal Documents 2.5 Benefits for prescriptions for Mail Order Maintenance Drugs submitted following SHL’s receipt of notice of Individual’s termination will be limited to the appropriate Maintenance Supply as defined herein, from the date such notice of termination is received to the Effective Date of termination of the Individual. Mail Order Plan Pharmacy Benefit Payments Form No. SHL-IPPO-3TierSIO-2004 2.3 Benefits for certain Covered Drugs are limited to a specific number of Therapeutic Supplies during a Dispensing Period as defined herein. If the applicable number of Therapeutic Supplies is exceeded prior to the expiration of the Dispensing Period, no benefits are payable until the commencement of any following Dispensing Period. 2.4 A Pharmacy may refuse to fill a prescription order or refill when in the professional judgment of the pharmacist the prescription should not be filled. 3. No benefits are payable if the EME of the Covered Drug is less than the applicable Covered Drug Fee. 1.3 2.2 Mail Order benefits only apply to Maintenance Drugs as defined herein. Prescription Drug Rider 3.2 Drugs which are available without charge under local, state, or federal programs, including Workers’ Compensation programs, or approved clinical trial or study; 3.14 Prescriptions for Covered Drugs that exceed the applicable number of Therapeutic Supplies in a given Dispensing Period as determined by SHL; 3.15 Any drug that has been approved by the FDA for less than nine (9) months unless Prior Authorized by SHL; 3.3 Devices of any type, including those prescribed by a licensed Provider, except for prescription contraceptive devices; 3.16 Drugs and medicines approved by the FDA for experimental or investigational use except when prescribed for the treatment of cancer or chronic fatigue syndrome under a clinical trial or study approved by the Plan; 3.4 Anorexic agents (weight reducing drugs), drugs prescribed for cosmetic purposes, hair growth, infertility drugs, nicotine suppressants, or erectile dysfunction drugs; 3.5 Hypodermic needles, syringes, or similar devices used for any purpose other than the administration of Self-Injectable Covered Drugs; 3.17 Compounds that are determined not to be Medically Necessary or are not Prior Authorized by SHL; and 3.18 Any class of Prescription Drugs for which an over-the-counter therapeutic equivalent is available. 3.6 Except as otherwise specifically provided, Prescription Drugs related to medical services which are not covered under the SHL AOC; SECTION 4. Glossary 3.7 Drugs for which prescriptions are written by a licensed Provider for use by the Provider or by his or her immediate family members; 4.1 “Brand Name Drug” is a Prescription Drug which is marketed under or protected by: • a registered trademark; or 3.8 Prescription Drugs dispensed prior to the Insured’s Effective Date of coverage or after Insured’s termination date of coverage under the Plan; • a registered trade name; or • a registered patent. 3.9 Over-the-counter drugs, multivitamins and nutritional supplements; 4.2 “Compound” means to form or create a Medically Necessary customized composite product by combining two (2) or more different ingredients according to a Physician’s specifications to meet an individual patient’s need. 3.10 Any Prescription Drug for which the actual charge to the Insured is less than the amount due under this Rider; 3.11 Any refill in excess of the amount specified by the prescription order; 4.3 “Coinsurance” means the percentage of the charges billed or the percentage of Eligible Medical Expenses that an Insured must pay to the Non-Plan Pharmacy for Covered Drugs. 3.12 Any refill dispensed; 1) more than one (1) year from the date of the latest prescription order or as permitted by applicable law of the jurisdiction in which the drug is dispensed; or 2) as a result of a lost or stolen prescription; 4.4 “Covered Drug” is a Brand Name or Generic Prescription Drug which: • can only be obtained with a prescription; 3.13 Medical supplies unless listed in the Preferred list or Prior Authorized by SHL; Form No. SHL-IPPO-3TierSIO-2004 Page 4 (NV 2003\SHL IPPO) 41NVSHLRI_RXDAP Prescription Drug Rider • has been approved by the Food and Drug Administration (“FDA”) for general marketing, subject to 3.15 above; conditions as determined by SHL to include but not be limited to the following: Diabetes, Arthritis, Heart Disease and High Blood Pressure. For purposes of this Rider, Maintenance Drugs do not include Self-Injectable or Orphan Covered Drugs other than those for the treatment of Diabetes. • is dispensed by a licensed pharmacist; • is prescribed by a licensed Provider; • is a Prescription Drug that does not have an over-the-counter therapeutic equivalent available; and • is not specifically excluded herein. 4.5 “Dispensing Period” as established by SHL means 1) a predetermined period of time; or 2) a period of time up to a predetermined age attained by the Insured that a specific Covered Drug is recommended by the FDA to be an appropriate course of treatment when prescribed in connection with a particular condition. 4.7 “Eligible Medical Expense (EME)” for purposes of this Rider, means the Plan Pharmacy contracted cost of the Covered Drug to SHL but not more than the actual charge to the Insured. 4.8 “Generic Drug” is an FDA-approved Prescription Drug which does not meet the definition of a Brand Name Drug as defined herein. 4.9 “Mail Order Plan Pharmacy” is a duly licensed pharmacy that has an independent contractor agreement with SHL to provide certain Preferred Maintenance Drugs to Insureds by mail. 4.13 “Non-Preferred” for purposes of this Rider, means those Covered Drugs not included on the Preferred list. 4.14 “Orphan Drugs” means a Prescription Drug for the treatment or prevention of a rare disease or condition as determined by the FDA. A rare disease is one that affects less than 200,000 people in the U.S. or one that affects more than 200,000 people but for which there is no reasonable expectation that the cost of developing the drug and making it available will be recovered from sales of that drug in the U.S. 4.15 “Plan Pharmacy” is a duly licensed pharmacy that has an independent contractor agreement with SHL to provide Covered Drugs to Insureds. Unless otherwise specified as Mail Order Plan Pharmacy herein, Plan Pharmacy services are retail services only and do not include Mail Order services. 4.16 “Preferred” or “Preferred Drug List (PDL)” means a list of FDA approved Generic and Brand Name Prescription Drugs established, maintained and recommended for use by SHL. 4.10 “Maintenance Drug” is a Preferred Covered Drug prescribed to treat certain chronic or life-threatening long-term Form No. SHL-IPPO-3TierSIO-2004 4.12 “Non-Plan Pharmacy” is a duly licensed pharmacy that does not have an independent contractor agreement with SHL to provide Covered Drugs to Insureds. Page 5 (NV 2003\SHL IPPO) 41NVSHLRI_RXDAP Legal Documents 4.6 “Drug Fee” is the predetermined amount shown in this Rider that the Insured is responsible for paying directly to the Plan Pharmacy for each Therapeutic Supply of a Covered Drug at the time the prescription is dispensed. Drug Fees or any amounts paid in addition to the Drug Fee do not apply to the Coinsurance and/or Copayment Maximum set forth in the Attachment A Benefit Schedule, if any. 4.11 “Maintenance Supply” is the quantity, as determined by SHL, of a Preferred Maintenance Drug for which Mail Order benefits are available for a specified number of Drug Fees or Coinsurance amount, and may be less than but shall not exceed a 90-day supply. Prescription Drug Rider 4.17 “Prescription Drug” is any drug required by federal law or regulation to be dispensed upon written prescription including finished dosage forms and active ingredients subject to the Federal Food, Drug and Cosmetic Act. The Plan’s PDL is subject to change during the year based on P&T Committee decisions and recommendations. Questions about the Plan’s PDL should be directed to the Member Services Department at (702) 242-7700 or 1-800-888-2264 (Fax: (702) 240-6281) from 8:00 a.m. – 5:00 p.m. Pacific Time. 4.18 “Self-Injectable” Covered Drug is an injectable Covered Drug, which is to be administered subcutaneously or intramuscularly, which does not require administration by a licensed Practitioner. Injectable Covered Drugs meeting this definition are considered Self-Injectable Covered Drugs even when administered by a licensed Practitioner or someone other than the Insured. 4.19 “Therapeutic Supply” is the maximum quantity of a Covered Drug for which benefits are available for a single applicable Drug Fee or the applicable Coinsurance amount and may be less than but shall not exceed a 30-day supply. Important Notice regarding the Preferred Drug List (PDL) The PDL is developed and maintained by the Plan’s Pharmacy and Therapeutics (P&T) Committee, which is comprised of Primary Care and Specialty Physicians, pharmacists and other healthcare Providers. The Committee meets at least annually and as needed throughout the year to evaluate the PDL and review new and existing categories of drugs. Drugs and drug classes are evaluated based upon FDA-approved indications, effectiveness, adverse effect profile, patient monitoring requirements, patient dosage and administration guidelines, impact on total healthcare costs, and comparison to other drugs on the PDL. Cost becomes a determining factor when minimal or no differences exist when comparing effectiveness with other drug specific parameters. The Committee uses medical and clinical literature, relevant patient utilization and experience, current therapeutic guidelines, economic data, and Provider recommendations in its decision-making process. Form No. SHL-IPPO-3TierSIO-2004 Page 6 (NV 2003\SHL IPPO) 41NVSHLRI_RXDAP