Prescription Drug Coverage – Plan Design

WIBA/MAXORPLUS OUTPATIENT PRESCRIPTION DRUG COVERAGE

WIBA/MaxorPlus Outpatient Prescription Drug Plan is a voluntary stand alone GENERIC
PRESCRIPTION PROGRAM. All WIBA/MaxorPlus enrollment data on the Rx plan will be transmitted to MaxorPlus for benefit establishment and the issuance of your I.D. cards.

This is a limited generic formulary plan with a $15 copay per prescription and a $2,500 annual maximum. The Pharmacy Benefit Manager for this plan will be MaxorPlus.

Covered Drugs
Dispensed as prescribed up to a 34-day supply or 100 doses. Federal Drugs, Compound prescriptions, State restricted drugs, Class V Drugs, Oral Contraceptives.

Coverage Guidelines
Unless Sole Proprietor, must have 2 enrolled in group and at least 75% employee, dependent participation. Employer must contribute 50% of total Capitated amount. No retiree groups. Open enrollment current employees must enroll within 30 days of the effective date. Rates will be effective from 01/01/07 to 12/31/07.

Coverage will be effective on the 1st of the month following receipt and approval of enrollment application. Enrollment application must be received within 30 days of the effective date. Coverage is written for one year and will terminate unless renewed by the company.

OUTPATIENT PRESCRIPTION DRUG EXCLUSIONS
Prescription Drug benefits are not payable for the following items:

All over-the-counter products and medications unless shown under the definition of Prescription Drug. This includes, but is not limited to, electrolyte replacement, infant formulas, miscellaneous nutritional supplements and all other over-the-counter products and medications.

• Blood glucose meters, insulin-injecting devices.
• Depo-Provera; levonorgestral: condoms, contraceptive sponges, and spermicides; sexual dysfunction drugs.
• Biologicals (including allergy tests): blood products: growth hormones; hemophiliac factors; MS injectables; immunizations; all other indictable unless shown under the definition of Prescription Drug.
• Aerochamber, Aerochamber with Mask; Peak Flow Meter; all other medical supplies and durable medical equipment unless shown under the definition of Prescription Drug.
• Liquid Nutritional Supplements, pediatric Legend Drug Vitamins; prenatal Legend Drug vitamins; prescribed versions of Vitamins A, D, K, B12, Folic Acid and Niacin used in treatment versus as a dietary supplement; all other Legend Drug vitamins and nutritional supplements.
• Anorexiants; any cosmetic drugs including, but not limited to, Renova, skin pigmentation preps; any drugs or products used for the treatment of baldness; Topical dental fluorides.
• Refills in excess of that specified by the prescribing Physician; or refills dispensed after one year from the original date of the prescription.
• Any drugs labeled Caution--limited by Federal Law for Investigational Use; or experimental drugs.
• Any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment.
• Drugs needed due to conditions caused, directly or indirectly, by a Person taking part in a riot or other civil disorder; or the Person taking part in the commission of a felony.
• Drugs needed due to conditions caused, directly or indirectly, by declared or undeclared war or an act of war; or drugs dispensed to a Person while on active duty in any armed force.
• Any expenses related to the administration of any drug.
• Needles or syringes unless shown under the definition of Prescription Drug.
• Drugs or medicines taking while in or administered by a hospital or any other health care facility or office.
• Drugs covered under Worker Compensation, Medicare, Medicaid or other Governmental program.
• Drugs, medicines, or products which are not medically necessary.
• Diaphragms, Erectile dysfunction Legend Drugs.
• Epi-Pen, Epi-Pen Jr. Ana-Kit, Ana-Guard; Glucagon-auto injection; Imitrex-auto injection.
• Smoking deterrents, Legend or over-the-counter.
• Brand Name Drugs.