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Contraceptive devices Prescription vitamins including prescription fluoride supplements as well as those covered under the Affordable Care Act* Influenza immunizations and those immunizations covered under the Affordable Health Care Act* Certain supplies and equipment are covered such as diabetic test strips, lancets, swabs, glucose monitors, insulin pumps and inhaler spacers. Contact Medco to determine approved covered supplies. If certain supplies, equipment or appliances are not available through the prescription benefit, they may be available through the medical benefit. Injectables unless otherwise noted as benefit exclusions. Prescription medical foods such as nutritional supplements, infant formulas, supplements to treat inherited metabolic diseases (including PKU) Prescription and some OTC smoking cessation drugs with limits of 180 days of therapy per year for nicotine, bupropion/ Zyban and for Chantix* Select pharmacogenomic tests used to guide the selection and dosing of medications.

Non-Covered Prescription Drug Benefits Over the counter drugs except insulin and those covered under the Affordable Health Care Act* Over the counter vitamins except those covered under the Affordable Health Care Act* Estriol compounds Emergency contraceptives (i.e. Plan B) Medications used for cosmetic purposes only such as hair growth stimulants Allergy sera Blood and blood plasma products except for hemophilia factors Experimental/ Investigative Drugs Drugs for treatment of sexual or erectile dysfunctions or inadequacies, regardless of origin or cause. Drug treatment related to infertility. Over the counter homeopathic or herbal medicines

*Certain prescription and OTC medications are considered preventative by the Affordable Care Act and are covered by the benefit. A prescription is required to obtain these preventative medications through your prescription benefit. For more information, contact Medco Customer Service at 877-841-5241.

If your medication is in a category not covered by the prescription drug benefit, please check with your medical carrier as it may be covered by that benefit. Example: allergy sera.

Deductible/Coinsurance/Copayment Each prescription order may be subject to a deductible and coinsurance/copayment. If the prescription order includes more than one covered drug, a separate coinsurance/ copayment will apply to each covered drug. The amount you pay for your prescription drugs will be no less than the minimum copay (unless the usual and customary retail price is less than the minimum copay)

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