Common use of Benefit Limitations Clause in Contracts

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 days at retail option, you will be charged one copayment per 30-day supply up to a maximum of a 90-day supply. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will receive credit towards their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-giver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- threatening conditions. Specialty Pharmaceuticals are often high cost, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional day supply limitations. Most Specialty Pharmaceuticals must be obtained through the specialty pharmacy network. For a complete list of these drugs and formulary coverage, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspx. You can call our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy network, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Prescriptions Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 days at retail option, you will be charged one copayment per 30-day supply up to a maximum of a 90-day supply. You will be charged three applicable Copayments for up to a 90-day supply up to the maximum dosing recommended by the manufacturer/FDA. • Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards toward their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. rebate.‌‌ Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- life-threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high cost, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional are limited to an initial fill up to a 15-day supply limitations. Most Specialty Pharmaceuticals must be obtained through to ensure patients can tolerate the specialty pharmacy networknew medication. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000.pdf. You can call our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy networkat (000) 000-0000 or 1-800-923- 6980, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 days at retail option, you will be charged one copayment Copayment per 30-day supply up to a maximum of a 90-day supply. supply.‌‌ Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high costcosts, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional day supply limitations. Most Specialty Pharmaceuticals must be obtained through the specialty pharmacy network. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000.pdf. You can call contact our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy network, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 01-000800- 356-000-0000. 2219, Monday through Friday from7 a.m. to 6 p.m. Hearing impaired users may call TTY 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 90-days at retail option, you will be charged one copayment per 30-day supply up to a maximum of a 90-day supply. You will be charged three applicable Copayments for up to a 90-day supply up to the maximum dosing recommended by the manufacturer/FDA. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- life-threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high cost, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional are limited to an initial fill up to a 14-day supply limitations. Most Specialty Pharmaceuticals must be obtained through to ensure patients can tolerate the specialty pharmacy networknew medication. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdfxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxpdf. You can call contact our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy network, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY line at 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose chose the 90 days at retail option, you will be charged one on copayment per 30-day supply up to a maximum of a 90-day supply. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards toward their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- life-threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high cost, typically greater than $600 for up to a 30-day supply. • Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional day supply limitations. • Most Specialty Pharmaceuticals must be obtained through the specialty pharmacy Specialty Pharmaceutical network. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxat‌‌ xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000.pdf. You can call our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy networkCenter, Monday through Friday Friday, from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Prescriptions Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 days at retail option, you will be charged one copayment per 30-day supply up to a maximum of a 90-day supply. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards toward their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- life-threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high cost, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional day supply limitations. Most Specialty Pharmaceuticals must be obtained through the specialty pharmacy network. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000.pdf. You can call our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy networkat (000) 000-0000 or 1-800-923- 6980, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 90-days at retail option, you will be charged one copayment Copayment per 30-day supply up to a maximum of a 90-day supply. You will be charged three applicable Copayments for up to a 90-day supply up to the maximum dosing recommended by the manufacturer/FDA. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Pharmaceuticals‌‌ Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high costcosts, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional are limited to an initial fill up to a 15-day supply limitations. Most Specialty Pharmaceuticals must be obtained through to ensure patients can tolerate the specialty pharmacy networknew medication. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- servicesxxxx://xxxx.xxx.xxx/idc/groups/public/documents/ communication/Pages/pharmacy-services.aspxpel_00000000.pdf. You can call contact our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy network, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. , Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-In- network Pharmacy. If you choose the 90 days at retail option, you will be charged one copayment per 30-day supply up to a maximum of a 90-day supply. You will be charged three applicable Copayments for up to a 90-day supply up to the maximum dosing recommended by the manufacturer/FDA. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Pharmaceuticals‌‌ Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- life-threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high cost, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional are limited to an initial fill up to a 15-day supply limitations. Most Specialty Pharmaceuticals must be obtained through to ensure patients can tolerate the specialty pharmacy networknew medication. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000.pdf. You can call contact our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy networkat (000) 000-0000 or 1-800- 923-6980, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Prescriptions Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 90-days at retail option, you will be charged one copayment per 30-day supply up to a maximum of a 90-day supply. You will be charged three applicable Copayments for up to a 90-day supply up to the maximum dosing recommended by the manufacturer/FDA. • Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards toward their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- life-threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high cost, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional are limited to an initial fill up to a 14-day supply limitations. Most Specialty Pharmaceuticals must be obtained through to ensure patients can tolerate the specialty pharmacy networknew medication. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000.pdf. You can call our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy network, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY line at 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose chose the 90 days at retail option, you will be charged one on copayment per 30-day supply up to a maximum of a 90-day supply. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards toward their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Pharmaceuticals‌ Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-giver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- life-threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high cost, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional day supply limitations. Most Specialty Pharmaceuticals must be obtained through the specialty pharmacy network. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000.pdf. You can call our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy networkCenter, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs may require a Prior Authorization and some must be obtained through the specialty network. These drugs may be subject to a separate Copayment/Coinsurance to a maximum as outlined in your Summary of Benefits and Coverage.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 90-days at retail option, you will be charged one copayment Copayment per 30-day supply up to a maximum of a 90-day supply. You will be charged three applicable Copayments for up to a 90-day supply up to the maximum dosing recommended by the manufacturer/FDA. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Pharmaceuticals‌‌ Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high costcosts, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional are limited to an initial fill up to a 15-day supply limitations. Most Specialty Pharmaceuticals must be obtained through to ensure patients can tolerate the specialty pharmacy networknew medication. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000.pdf. You can call contact our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy network, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 90-days at retail option, you will be charged one copayment Copayment per 30-day supply up to a maximum of a 90-day supply. You will be charged three applicable Copayments for up to a 90-day supply up to the maximum dosing recommended by the manufacturer/FDA. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high costcosts, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional are limited to an initial fill up to a 14-day supply limitations. Most Specialty Pharmaceuticals must be obtained through to ensure patients can tolerate the specialty pharmacy networknew medication. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000.pdf. You can call contact our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy network, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY line at 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Prescriptions Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 90-days at retail option, you will be charged one copayment per 30-day supply up to a maximum of a 90-day supply. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards toward their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- life-threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high cost, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional day supply limitations. Most Specialty Pharmaceuticals must be obtained through the specialty pharmacy network. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxat‌‌ xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000.pdf. You can call our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy networkat (000) 000-0000 or 1-800- 923-6980, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 days at retail option, you will be charged one copayment per 30-day supply up to a maximum of a 90-day supply. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will receive credit towards their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-giver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- threatening conditions. Specialty Pharmaceuticals are often high cost, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional day supply limitations. Most Specialty Pharmaceuticals must be obtained through the specialty pharmacy network. For a complete list of these drugs and formulary coverage, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspx. You can call our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy network, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 days at retail option, you will be charged one copayment Copayment per 30-day supply up to a maximum of a 90-day supply. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- life-threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high cost, typically greater than $600 for up to a 30-day supply. · Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional day supply limitations. · Most Specialty Pharmaceuticals must be obtained through the specialty pharmacy Specialty Pharmaceutical network. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000.pdf. You can call our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy networkCenter, Monday through Friday Friday, from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 days at retail option, you will be charged one copayment Copayment per 30-day supply up to a maximum of a 90-day supply. supply.‌ Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high costcosts, typically greater than $600 for up to a 30-day supply. Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional day supply limitations. Most Specialty Pharmaceuticals must be obtained through the specialty pharmacy network. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/ pel_00000000.pdf. You can call contact our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy network, Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711.

Benefit Limitations. This benefit has one or more exclusions as specified in the Exclusions Section. You have the option to purchase up to a 90-day supply of Prescription Drugs/Medications. Under the up to a 90-day at Retail Pharmacy benefit, Preferred Generic, Non-Preferred Generic, Preferred Brand and Non-Preferred Drugs can be obtained from an In-network Pharmacy. If you choose the 90 days at retail option, you will be charged one copayment Copayment per 30-day supply up to a maximum of a 90-day supply. Some medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such medication where third-party copayment assistance is used (Discount Cards or Prescription Drug Savings Cards), the Member will shall not receive credit towards their maximum out-of-pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Self-Administered Specialty Pharmaceuticals Self-Administered Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-givercaregiver. Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life- threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network. Specialty Pharmaceuticals are often high cost, typically greater than $600 for up to a 30-day supply. · Specialty Pharmaceuticals are not available through the retail or mail order option and are limited to a 30-day supply. Certain Specialty Pharmaceuticals may have additional day supply limitations. · Most Specialty Pharmaceuticals must be obtained through the specialty pharmacy Specialty Pharmaceutical network. For a complete list of these drugs and formulary coveragedrugs, please see the Specialty Pharmaceutical listing at xxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00236101.pdf. For Specialty Pharmacy information please see the pharmacy services available at xxxxx://xxx.xxx.xxx/doctors-services/services-centers/supporting- services/Pages/pharmacy-services.aspxxxxx://xxxx.xxx.xxx/idc/groups/public/documents/communication/pel_00000000.pdf. You can call our Presbyterian Customer Service Center for additional information about the Presbyterian Specialty Pharmacy networkCenter, Monday through Friday Friday, from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711.