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Your Prescription Medication Plan provides coverage for services provided by Participating pharmacies as listed below.
Under this plan, benefits for preferred medications are covered at a higher benefit level. For assistance in locating a
Participating Pharmacy or the RegenceRx Preferred Medication List, please visit our Web site at www.or.regence.com.
Your Prescription Plan Features
Mail order service for medications taken regularly for chronic conditions.
Up to a 90-day supply for mail order medications is provided.
Up to a 30-day supply for self-injectable medications for mail order.
RegenceRx Preferred Medication List, which offers quality generics and selected brands includingcontraceptives.
Needles and syringes used for self-injectable medications.
Preferred copayment for medications on the RegenceRx Preferred Medication List.
Medications that are required by law to be dispensed by prescription.
Benefit Features
Important Note: Present your identification card with all new and refill prescriptions. There is a $10 processing fee
for all submitted paper claims.
Medications purchased at participating pharmacies
*The maximum quantity is a 34-day supply for each prescription filled.
Medications purchased through mail order
*The maximum quantity is a 90-day supply for each prescription filled.
Renewals effective on or after January 1, 2005 Traditional Flat $10/$20/$40 Copay Rx OR (04/04) Rev 09/04 Limitations and Exclusions
Once enrolled, your benefits booklet can be viewed online at our Web site, www.or.regence.com. Please refer to your benefits booklet for a complete list of benefits and the limitations and exclusions that apply. These Benefits Are Limited
! The maximum quantity for pharmacy purchased medications is a 34-day supply. Some medications may be limited
by quantity rather than day supply or may require prior authorization by the health plan.
! The maximum quantity for mail order purchased medications is a 90-day supply. Some medications may be limited by quantity rather than day supply or may require prior authorization by the health plan.
! The maximum quantity for mail order purchased self-injectable medications is a 30-day supply. Some medications may be limited by the quantity rather than day supply or may require prior authorization by the health plan.
! Compound medications are only covered when one ingredient is a federal legend or state restricted medication.
Services And Supplies Not Covered
! Prescription medications purchased at a non-participating pharmacy
! Impotence medications
! Fertility medications
! Nonprescription medications
! Medications prescribed for cosmetic purposes
! Medications with no proven therapeutic indication
! Retin-A for anyone 26 years of age or over
! Renova
! Lamisil and Sporanox
! Topical minoxidil
! Smoking cessation products
! Experimental or investigational medications
! Medications prescribed for weight loss or the treatment of obesity (including, but not limited to amphetamines)
! Vitamins and fluoride, except those required by law to be dispensed by prescription
! Injectable medications, except those defined as self-injectable
! Medications dispensed in a facility while a patient in a hospital, skilled nursing facility, nursing home, or other
! Stolen, lost, spilled, or destroyed prescription medications TDD Line for people with hearing impairments 1 (800) 382-1003 www.or.regence.com

Source: http://www.cityofalbany.net/images/stories/hr/healthcare/RBCBS-Pharmacy%20Benefit%20Summary.pdf