Common use of Benefits Specialty Drugs obtained at Fairview Clause in Contracts

Benefits Specialty Drugs obtained at Fairview. Specialty Pharmacy or other specialty pharmacy approved by PIC. PIC pays: For more information, contact Fairview Specialty Pharmacy at 612.672.5260 or 0.000.000.0000. NOTE: Certain specialty drugs may only be available by limited distribution through a manufacturer’s select specialty pharmacy and may not be available through Fairview Specialty Pharmacy or other specialty pharmacy approved by PIC. Benefits for such limited distribution specialty drugs will be paid the same as if they were obtained from Fairview Specialty Pharmacy or other specialty pharmacy approved by PIC. Specialty Drugs obtained at any pharmacy other than a specialty pharmacy approved by PIC. • Specialty drugs up to a 31– calendar day supply per prescription or refill that:  may be oral or injectable; and  Must be purchased through a specialty pharmacy. A list of these specialty drugs may be obtained on PIC’s website or by calling PIC Customer Service. The list of specialty drugs may be revised from time-to-time without notice. NOTE: Prescription drugs which PIC determines are specialty drugs will not be covered at the generic, preferred brand or mail order benefit level. Generic: 50% of eligible charges after the deductible. Preferred Brand: 50% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered.

Benefits Specialty Drugs obtained at Fairview. Specialty Pharmacy or other specialty pharmacy approved by PIC. PIC pays: For more information, contact Fairview Specialty Pharmacy at 612.672.5260 or 0.000.000.0000. NOTE: Certain specialty drugs may only be available by limited distribution through a manufacturer’s select specialty pharmacy and may not be available through Fairview Specialty Pharmacy or other specialty pharmacy approved by PIC. Benefits for such limited distribution specialty drugs will be paid the same as if they were obtained from Fairview Specialty Pharmacy or other specialty pharmacy approved by PIC. Specialty Drugs obtained at any pharmacy other than a specialty pharmacy approved by PIC. • Specialty drugs up to a 31– calendar day supply per prescription or refill that:  ✓ may be oral or injectable; and  ✓ Must be purchased through a specialty pharmacy. A list of these specialty drugs may be obtained on PIC’s website or by calling PIC Customer Service. The list of specialty drugs may be revised from time-to-time without notice. NOTE: Prescription drugs which PIC determines are specialty drugs will not be covered at the generic, preferred brand or mail order benefit level. Generic: 50% of eligible charges after the deductible. Preferred Brand: 50% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered.

Benefits Specialty Drugs obtained at Fairview. Specialty Pharmacy or other specialty pharmacy approved by PIC. PIC pays: For more information, contact Fairview Specialty Pharmacy at 612.672.5260 or 0.000.000.0000. NOTE: Certain specialty drugs may only be available by limited distribution through a manufacturer’s select specialty pharmacy and may not be available through Fairview Specialty Pharmacy or other specialty pharmacy approved by PIC. Benefits for such limited distribution specialty drugs will be paid the same as if they were obtained from Fairview Specialty Pharmacy or other specialty pharmacy approved by PIC. Specialty Drugs obtained at any pharmacy other than a specialty pharmacy approved by PIC. • Specialty drugs up to a 31– calendar day supply per prescription or refill that:  ✓ may be oral or injectable; and  ✓ Must be purchased through a specialty pharmacy. A list of these specialty drugs may be obtained on PIC’s website or by calling PIC Customer Service. The list of specialty drugs may be revised from time-to-time without notice. NOTE: Prescription drugs which PIC determines are specialty drugs will not be covered at the generic, preferred brand or mail order benefit level. Generic: 50100% of eligible charges after the deductible. Preferred Brand: 50100% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered.

Benefits Specialty Drugs obtained at Fairview. Specialty Pharmacy or other specialty pharmacy approved by PIC. PIC pays: For more information, contact Fairview Specialty Pharmacy at 612.672.5260 or 0.000.000.0000. NOTE: Certain specialty drugs may only be available by limited distribution through a manufacturer’s select specialty pharmacy and may not be available through Fairview Specialty Pharmacy or other specialty pharmacy approved by PIC. Benefits for such limited distribution specialty drugs will be paid the same as if they were obtained from Fairview Specialty Pharmacy or other specialty pharmacy approved by PIC. Specialty Drugs obtained at any pharmacy other than a specialty pharmacy approved by PIC. • Specialty drugs up to a 31– calendar day supply per prescription or refill that:  may be oral or injectable; and  Must be purchased through a specialty pharmacy. A list of these specialty drugs may be obtained on PIC’s website or by calling PIC Customer Service. The list of specialty drugs may be revised from time-to-time without notice. NOTE: Prescription drugs which PIC determines are specialty drugs will not be covered at the generic, preferred brand or mail order benefit level. Generic: 50100% of eligible charges after the deductible. Preferred Brand: 50100% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered.

Benefits Specialty Drugs obtained at Fairview. Specialty Pharmacy or other designated specialty pharmacy approved by PICpharmacy. PIC pays: For more information, contact Fairview Specialty Pharmacy at 612.672.5260 or 0.000.000.0000. NOTE: Certain specialty drugs may only be available by limited distribution through a the manufacturer’s select specialty pharmacy and may not be available through Fairview Specialty Pharmacy or other specialty pharmacy approved by PICPharmacy. Benefits for such limited distribution specialty drugs will be paid the same as if they were obtained from Fairview Specialty Pharmacy or other specialty pharmacy approved by PICPharmacy. Specialty Drugs obtained at any pharmacy other than a designated specialty pharmacy approved by PIC. pharmacy: • Specialty drugs up to a 31– calendar day supply per prescription or refill that:  may be oral or injectable; and  Must be purchased through a specialty pharmacy. A list of these specialty drugs may be obtained on PIC’s website or by calling PIC Customer Service. The list of specialty drugs may be revised from time-to-time without notice. NOTE: Prescription drugs which PIC determines are specialty drugs will not be covered at the tier 1 generic, tier 2 generic, preferred brand or mail order benefit level. Tier 1 Generic: 50% of eligible charges after the deductible. Tier 2 Generic: 50% of eligible charges after the deductible. Preferred Brand: 50% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered.