Common use of Coverage for Contraception Where a Prescription Is Not Required Clause in Contracts

Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no cost sharing even when a prescription is not required. Contraceptive methods such as condoms or Plan B may fall into this category. You will not have to pay upfront for contraceptives that do not require a prescription when obtained through an in-network pharmacy. For all other purchases, you may submit a request for reimbursement as follows: • Within 90 days of the date of purchase of the contraceptive method, • [Provide the receipt with the item name and amount, your name, address, plan ID number, to the following: Address: Presbyterian Health Plan X.X. Xxx 00000 Xxxxxxxxxxx, XX 00000-0000 Email: If you submit your complete request for reimbursement electronically or by fax, we will reimburse you within 30 days of receiving the request. If you submit your complete request for reimbursement by U.S. mail, we will reimburse within 45 days. Failure to submit a complete request may lead to delays in reimbursement. Availability of Out-of-Network Coverage Under your plan, use of an out-of-network provider to prescribe or dispense contraceptive coverage is not a covered benefit.] This endorsement is retroactive to the effective date of your coverage with us. These terms replace and supersede any conflicting provision of your insurance contract and summary of benefits and coverage. All other requirements of the policy not in conflict with this endorsement still apply. Table of Contents Endorsement 1 3 PRIOR AUTHORIZATION 3 Endorsement 2 6 OUT-OF-NETWORK CARE AND BILLS 6 If you pay an out-of-network provider more than we determine you owe: 7 Endorsement 3 8 NO COST SHARING FOR BEHAVIORAL HEALTH SERVICES 8 Endorsement 4 9 CONTRACEPTIVE COVERAGE SUMMARY ENDORSEMENT 9 Welcome 22 Welcome to Presbyterian Health Plan! 22 Our Agreement with You 22 Understanding This Agreement 23 Customer Assistance 24 Member Rights and Responsibilities 26 This Section explains your rights and responsibilities under this Agreement and how you can participate on our Consumer Advisory Board. Member Rights 26 Additional Member Rights and Responsibilities 27 Consumer Advisory Board 29 How the Plan Works 30 This section explains how to find Practitioners/Providers who are in our Network (In- network), get Healthcare Services both In-network and Out-of-network, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. Provider Directory 31 Obtaining Healthcare 31 How to Obtain Primary Care Services 31 Women’s Healthcare Provider/Practitioner 32 Specialist Care 32 Obtaining Care after Normal Provider Office Hours 32 In-Network Practitioners/Providers 33 Out-of-network Practitioners/Providers 33 Restrictions on Services Received Outside of the PHP Service Area 34 National Health Care Practitioner/Provider Network 35 Cost Sharing – Your Out-of-pocket Costs 35 Annual Contract Year Deductible 35 Changes to Deductible 36 Coinsurance 36 Annual Out-of-pocket Maximum 36 Office Visit Copayment 37 Utilization Management and Quality 37 Technology Assessment Committee 37 Transition of Care 38 Advance Directives 38 Prior Authorization 39 This Section explains what Covered Healthcare Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. What is Prior Authorization? 39 Prior Authorization Is Required 39 Prior Authorization when In-network 40 Prior Authorization when Out-of-network 40 Services That Require Prior Authorization In or Out-of-Network 41 Authorizing Inpatient Hospital Admission following an Emergency 43 Prior Authorization and Your Coverage 43 Prior Authorization Decisions – Non-Emergency 43 Prior Authorization Decision – Expedited (Accelerated) 43 Prior Authorization Review – Initial Adverse Determination 43

Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no cost sharing even when a prescription is not required. Contraceptive methods such as condoms or Plan B may fall into this category. You will not have to pay upfront for contraceptives that do not require a prescription when obtained through an in-network pharmacy. For all other purchases, you may submit a request for reimbursement as follows: • Within 90 days of the date of purchase of the contraceptive method, • [Provide the receipt with the item name and amount, your name, address, plan ID number, to the following: Address: Presbyterian Health Plan X.X. Xxx 00000 XxxxxxxxxxxP.O. Box 27489 Albuquerque, XX 00000NM 87125-0000 7489 Email: If you submit your complete request for reimbursement electronically or by fax, we will reimburse you within 30 days of receiving the request. If you submit your complete request for reimbursement by U.S. mail, we will reimburse within 45 days. Failure to submit a complete request may lead to delays in reimbursement. Availability of Out-of-Network Coverage Under your plan, use of an out-of-network provider to prescribe or dispense contraceptive coverage is not a covered benefit.] This endorsement is retroactive to the effective date of your coverage with us. These terms replace and supersede any conflicting provision of your insurance contract and summary of benefits and coverage. All other requirements of the policy not in conflict with this endorsement still apply. Table of Contents Endorsement 1 3 PRIOR AUTHORIZATION 3 Endorsement 2 6 OUT-OF-NETWORK CARE AND BILLS 6 If you pay an out-of-network provider more than we determine you owe: 7 Endorsement 3 8 NO COST SHARING FOR BEHAVIORAL HEALTH SERVICES 8 Endorsement 4 9 CONTRACEPTIVE COVERAGE SUMMARY ENDORSEMENT 9 Welcome 22 Welcome to Presbyterian Health Plan! 22 Our Agreement with You 22 Understanding This Agreement 23 Customer Assistance 24 Member Rights and Responsibilities 26 This Section explains your rights and responsibilities under this Agreement and how you can participate on our Consumer Advisory Board. Member Rights 26 Additional Member Rights and Responsibilities 27 Consumer Advisory Board 29 How the Plan Works 30 This section explains how to find Practitioners/Providers who are in our Network (In- network), get Healthcare Services both In-network and Out-of-network, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. Provider Directory 31 Obtaining Healthcare 31 How to Obtain Primary Care Services 31 Women’s Healthcare Provider/Practitioner 32 Specialist Care 32 Obtaining Care after Normal Provider Physician Office Hours 32 In-Network Practitioners/Providers 33 Out-of-network (outside of the 5-county area) Practitioners/Providers 33 Restrictions on Services Received Outside of the PHP Service Area 34 National Health Care Practitioner/Provider Network 35 Cost Sharing – Your Out-of-pocket Costs 35 Services for Limited Plans for American Indians and Alaska Natives 35 Annual Contract Year Deductible 35 Changes to Deductible 36 Coinsurance 36 Annual Out-of-pocket Maximum 36 Office Visit Copayment 37 Utilization Management and Quality 37 Technology Assessment Committee 37 Transition of Care 38 Advance Directives 38 Prior Authorization 39 This Section explains what Covered Healthcare Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. What is Prior Authorization? 39 Prior Authorization Is Required 39 Prior Authorization when In-network 40 Prior Authorization when Out-of-network (outside of the 5-county area) 40 Services That Require Prior Authorization In or Out-of-Network network (outside of the 5-county area) 41 Authorizing Inpatient Hospital Admission following an Emergency 43 Prior Authorization and Your Coverage 43 Prior Authorization Decisions – Non-Emergency 43 Prior Authorization Decision – Expedited (Accelerated) 43 Prior Authorization Review – Initial Adverse Determination 43

Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no cost sharing even when a prescription is not required. Contraceptive methods such as condoms or Plan B may fall into this category. You will not have to pay upfront for contraceptives that do not require a prescription when obtained through an in-network pharmacy. For all other purchases, you may submit a request for reimbursement as follows: • Within 90 days of the date of purchase of the contraceptive method, • [Provide the receipt with the item name and amount, your name, address, plan ID number, to the following: Address: Presbyterian Health Plan X.X. Xxx 00000 Xxxxxxxxxxx, XX 00000-0000 Email: If you submit your complete request for reimbursement electronically or by fax, we will reimburse you within 30 days of receiving the request. If you submit your complete request for reimbursement by U.S. mail, we will reimburse within 45 days. Failure to submit a complete request may lead to delays in reimbursement. Availability of Out-of-Network Coverage Under your plan, use of an out-of-network provider to prescribe or dispense contraceptive coverage is not a covered benefit.] This endorsement is retroactive to the effective date of your coverage with us. These terms replace and supersede any conflicting provision of your insurance contract and summary of benefits and coverage. All other requirements of the policy not in conflict with this endorsement still apply. Table of Contents Endorsement 1 3 ........................................Error! Bookmark not defined. PRIOR AUTHORIZATION 3 Error! Bookmark not defined. Endorsement 2 6 ........................................Error! Bookmark not defined. OUT-OF-NETWORK CARE AND BILLS 6 If you pay an out-of-network provider more than we determine you owe: 7 Endorsement 3 8 NO COST SHARING FOR BEHAVIORAL HEALTH SERVICES 8 Endorsement 4 9 CONTRACEPTIVE COVERAGE SUMMARY ENDORSEMENT 9 Error! Bookmark not defined. Welcome 22 Welcome to Presbyterian Health Plan! 22 Our Agreement with You 22 Understanding This Agreement 23 Customer Assistance 24 Member Rights and Responsibilities 26 This Section explains your rights and responsibilities under this Agreement and how you can participate on our Consumer Advisory Board. Member Rights 26 Additional Member Rights and Responsibilities 27 Consumer Advisory Board 29 How the Plan Works 30 This section explains how to find Practitioners/Providers who are in our Network (In- network), get Healthcare Services both In-network and Out-of-network, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. Provider Directory 31 Obtaining Healthcare 31 How to Obtain Primary Care Services 31 Women’s Healthcare Provider/Practitioner 32 Specialist Care 32 Obtaining Care after Normal Provider Office Hours 32 In-Network Practitioners/Providers 33 Out-of-network Practitioners/Providers 33 Restrictions on Services Received Outside of the PHP Service Area 34 National Health Care Practitioner/Provider Network 35 Cost Sharing – Your Out-of-pocket Costs 35 Services for Limited Plans for American Indians and Alaska Natives 35 Annual Contract Year Deductible 35 36 Changes to Deductible 36 Coinsurance 36 Annual Out-of-pocket Maximum 36 Office Visit Copayment 37 Utilization Management and Quality 37 Technology Assessment Committee 37 38 Transition of Care 38 Advance Directives 38 Prior Authorization 39 40 This Section explains what Covered Healthcare Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. What is Prior Authorization? 39 40 Prior Authorization Is Required 39 40 Prior Authorization when In-network 40 41 Prior Authorization when Out-of-network 40 41 Services That Require Prior Authorization In or Out-of-Network 41 42 Authorizing Inpatient Hospital Admission following an Emergency 43 44 Prior Authorization and Your Coverage 43 44 Prior Authorization Decisions – Non-Emergency 43 44 Prior Authorization Decision – Expedited (Accelerated) 43 44 Prior Authorization Review – Initial Adverse Determination 4344

Coverage for Contraception Where a Prescription Is Not Required. Your plan covers contraception with no cost sharing Cost Sharing, after the deductible is met, even when a prescription Prescription is not required. Contraceptive methods such as condoms or Plan B may fall into this category. You will not have to pay upfront for contraceptives that do not require a prescription Prescription when obtained through an inIn-network pharmacyPharmacy. For all other purchases, you may submit a request for reimbursement as follows: •  Within 90 days of the date of purchase of the contraceptive method, • [method  Provide the receipt with the item name and amount, your name, address, plan ID number, to the following: Address: Presbyterian Health Plan X.X. Xxx 00000 XxxxxxxxxxxInsurance Company, XX 00000Inc. Pharmacy Department P.O. Box 26267 Albuquerque, NM 87125-6267 Email: xxxxxxxxxxx@xxx.xxx Fax: (000) 000-0000 Email: If you submit your complete request for reimbursement electronically or by fax, we will reimburse you within 30 days of receiving the request. If you submit your complete request for reimbursement by U.S. mail, we will reimburse within 45 days. Failure Please ensure all information on the reimbursement request is complete to submit a complete request may lead to delays in reimbursementprevent any delays. Availability of Out-of-Network Coverage Under your plan, use of an outOut-of-network provider Provider to prescribe or dispense contraceptive coverage is not a covered benefit.] This endorsement is retroactive . Please refer to the effective date of your coverage with us. These terms replace and supersede any conflicting provision of your insurance contract and summary of benefits and coverage. All other requirements of the policy not in conflict with this endorsement still apply. Table of Contents Endorsement 1 3 PRIOR AUTHORIZATION 3 Endorsement 2 6 OUT-OF-NETWORK CARE AND BILLS 6 If you pay an out-of-network provider more than we determine you owe: 7 Endorsement 3 8 NO COST SHARING FOR BEHAVIORAL HEALTH SERVICES 8 Endorsement 4 9 CONTRACEPTIVE COVERAGE SUMMARY ENDORSEMENT 9 Welcome 22 Welcome to Presbyterian Health Plan! 22 Our Agreement with You 22 Understanding This Agreement 23 Customer Assistance 24 Member Rights and Responsibilities 26 This Section explains your rights and responsibilities under this Agreement and how you can participate on our Consumer Advisory Board. Member Rights 26 Additional Member Rights and Responsibilities 27 Consumer Advisory Board 29 How the Plan Works 30 This section explains how to find Practitioners/Providers who are in our Network (In- network), get Healthcare Services both In-network and Out-of-network, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. Provider Directory 31 Obtaining Healthcare 31 How to Obtain Primary Care Services 31 Women’s Healthcare Provider/Practitioner 32 Specialist Care 32 Obtaining Care after Normal Provider Office Hours 32 In-Network Practitioners/Providers 33 Section Out-of-network Practitioners/Providers 33 Restrictions on Services Received Outside of the PHP Service Area 34 National Health Care Practitioner/Provider Network 35 Cost Sharing – Your and Bills to learn more about your Out-of-pocket Costs 35 Annual Contract Year Deductible 35 network benefit. What is a Formulary? A drug Formulary, or preferred drug list, is a continually updated list of medications and related products supported by current evidence-based medicine, judgement of physicians, pharmacists and other experts in the diagnosis and treatment of disease and preservation of health. The primary purpose of the Formulary is to encourage the use of safe, effective and most affordable medications. Presbyterian Insurance Company, Inc. administers a closed Formulary, which means that Non-formulary drugs are not routinely reimbursed by the plan. Medical exception policies provide access to Non-formulary medication when Medical Necessity is established. The medications listed on the Formulary are subject to change pursuant to the management activities of Presbyterian Insurance Company, Inc. For the most up-to-date Formulary drug information, visit xxxxx://xxxxxx.xxxxxxxxxxxxxxxxxx.xxx/Search.aspx?siteCode=0324498195. Presbyterian will provide material that contains in a clear, conspicuous and readily understandable form, a full and fair disclosure of the plan’s benefits, limitations, exclusions, conditions of eligibility and Prior Authorization requirements, within a reasonable time after enrollment and at subsequent periodic times as appropriate. Can the Formulary change during the year? The Formulary can change throughout the year. Some reasons why it can change include:  New drugs are approved  Existing drugs are removed from the market.  Prescription drugs may become available over the counter (without a prescription)  Brand-name drugs lose patent protection and generic versions become available  Changes based on new clinical guidelines If we remove drugs from our Formulary, add quantity limits, Prior Authorization, and/or step therapy restrictions on a drug, or move a drug to a higher Cost-Sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective. If your plan provides prescription drug benefits that applies a deductible or coinsurance cost share, Presbyterian will not make any of the following changes to coverage for a prescription drug within 120 days of any previous change to coverage for that prescription drug, unless a generic version of the prescription drug is available.  Reclassify a drug to a higher tier of the formulary.  Reclassify a drug from a preferred classification to a non-preferred classification, unless that Reclassification results in the drug moving to a lower tier of the formulary.  Increase the cost-sharing, copayment, deductible or co-insurance charges for a drug.  Remove a drug from the formulary.  Establish a prior authorization requirement.  Impose or modify a drug's quantity limit; or  Impose a step-therapy restriction. How is the Formulary Drug List Developed? The medications and related products listed on a Formulary are determined by a Pharmacy and Therapeutics (P & T) Committee or an equivalent entity. The Presbyterian Insurance Company, Inc., P & T Committee is made up of primary care and specialty physicians, clinical pharmacists and other professionals in the healthcare field. The P & T Committee meets quarterly to promote the appropriate use of drugs, to maintain the Presbyterian formularies, and to support our network of practitioners. Medications chosen for the Formulary are selected based on their safety, effectiveness and overall value. A medication may not be added to the Formulary if current drugs on the Formulary are equally safe and effective and are less costly. Utilization management strategies such as quality limits, step therapy and Prior Authorization criteria are reviewed and approved by the P & T Committee. Medication coverage criteria is updated and reviewed to reflect current standards of practice. The overall goal of the P & T Committee is to provide a Formulary that gives Members access to safe, appropriate, and cost-effective medications that will produce the desired goals of therapy at the most reasonable cost to the member and the healthcare system. Changes to Deductible 36 Coinsurance 36 Annual Outthe Presbyterian Formulary are made effective at least 45 days after the quarterly meeting. If a change to the Formulary negatively impacts utilizing members, the members are granted a 60-of-pocket Maximum 36 Office Visit Copayment 37 Utilization Management day transition period. Members impacted will receive a Formulary Change Notification letter with details about the change, the effective date of the change and Quality 37 Technology Assessment Committee 37 Transition of Care 38 Advance Directives 38 Prior Authorization 39 This Section explains what Covered Healthcare Services require Prior Authorization before you receive these services and how to obtain Prior AuthorizationFormulary alternatives if available. What is Prior Authorization? 39 Prior Authorization Is Required 39 is a clinical evaluation process to determine if the requested Healthcare Service is Medically Necessary, a Covered Benefit, and if it is being delivered in the most appropriate healthcare setting. Our Medical Director or other clinical professional will review the requested Healthcare Service in consultation with your medical provider, and if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization when Inprocess and requirements are regularly reviewed and updated based on various factors including evidence-network 40 based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures.  When all necessary information is provided with the Drug Prior Authorization request, standard requests are processed as expeditiously as the member’s health requires, within 72 hours after the request is received.  When a member or their provider believes that waiting for a decision under the standard time frame could place the member’s life, health or ability to regain maximum function in jeopardy, a PA can be expedited. These requests are processed within 24 hours after the request is received.  Continuation of therapy using any drug is dependent upon its demonstrable efficacy.  Prior use of free prescription medications (i.e., samples, free goods, etc.) will not be considered in the evaluation of a member’s eligibility for medication coverage. Prescribed drugs will be considered for coverage under the pharmacy benefit when Outall of the following are met:  The medication is being prescribed for an FDA approved indication OR the patient has a diagnosis which is considered medically acceptable in the approved compendia* or a peer-ofreviewed medical journal.  The patient does not have any contraindications or significant safety concerns with using the prescribed drug.  If the patient does not meet the above criteria, the prescribed use is considered Experimental or Investigational for Conditions not listed in this section of Evidence of Coverage.  *The approved compendia includes: o American Hospital Formulary Service (AHFS) Compendium. o IBM Micromedex Compendium. o Elsevier Gold Standard’s Clinical Pharmacology Compendium. o National Comprehensive Cancer Network Drugs and Biologics Compendium. What is Step Therapy? Step Therapy promotes the appropriate use of equally effective but lower-network 40 Services That Require Prior Authorization In cost Formulary drugs first. With this program, prior use of one or Outmore “prerequisite” drugs is required before a step- therapy medication will be covered. Prerequisite drugs are FDA-ofapproved and treat the same condition as the corresponding step-Network 41 Authorizing Inpatient Hospital Admission following an Emergency 43 Prior Authorization therapy drugs. Presbyterian will not impose step therapy requirements before authorizing coverage for medication approved by the Federal Food and Your Coverage 43 Prior Authorization Decisions – NonDrug Administration (FDA) that is prescribed for the treatment of a substance use disorder, pursuant to a medical necessity determination, except in cases in which a generic version is available. What are Quantity Limits? Formulary drugs may also limit coverage of quantities for certain drugs. These limits help your doctor and pharmacist check that the medications are used appropriately and promote patient safety. Presbyterian uses medical guidelines and FDA-Emergency 43 Prior Authorization Decision – Expedited approved recommendations from drug makes to set these coverage limits. Quantity limits include the following:  Maximum Daily Dose limits quantities to a maximum number of dosage units (Acceleratedi.e., tablets, capsules, milliliters, milligrams, doses, etc.) 43 Prior Authorization Review – Initial Adverse Determination 43in a single day. Limits are based on daily dosages shown to be safe and effective, and that are approved by the Food and Drug Administration (FDA).  Quantity Limits over time limits quantities to number of units (i.e., tablets, capsules, milliliters, milligrams, doses, etc.) in a defined period of time.