Common use of Coverage Policies and Guidelines Clause in Contracts

Coverage Policies and Guidelines. SHLs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on SHL’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician. When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person is a determination that is made by the Covered Person and the prescribing Physician. NOTE: the tier status of a Prescription Drug may change periodically based on the process described above but only at times specified by NRS 687B.4095 . As a result of such changes, you may be required to pay more or less for that Prescription Drug. Questions about SHL’s PDL should be directed to the Member Services Department at 000-000-0000 or the PDL and the Pharmacy Reimbursement Claim Form is available at xxxxx://xxxxxxxxxxxxxxxxxxx.xxx/~/media/Files/SHL/pdf/Forms/Pharmacy-Reimbursement- Claim-Form.ashx?la=en. SHL may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the Insured’s annual CYD and/or Out of Pocket Maximum or to reduce the Insured’s Copayments and/or Coinsurance. Costs defrayed for the Insured as a result of pharmaceutical coupons are not Eligible Expenses. Questions regarding which coupons or offers are available can be addressed at xxxxxxxxxxxxxxxxxxx.xxx. SHL may receive rebates for certain drugs included on the Prescription Drug List, including those drugs that an Insured purchased prior to meeting any applicable deductible. As determined by SHL, a portion of any rebates may be passed on to the Insured and may be taken into account in determining any applicable Copayment and/or Cost-share. SHL, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers separate and apart from the Outpatient Prescription Drug benefit. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient Prescription Drug benefit and, therefore, such amounts do not pass on to the Insured.

Coverage Policies and Guidelines. SHLs HPNs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on SHLHPN’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including including, but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician. When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons covered persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person covered person is a determination that is made by the Covered Person covered person and the prescribing Physician. NOTE: the tier status of a Prescription Drug may change periodically based on the process described above but only at times specified by NRS 687B.4095 . As a result of such changes, you may be required to pay more or less for that Prescription Drug. Questions about SHLHPN’s PDL should be directed to the Member Services Department at 000-000-0000 or the PDL and the Pharmacy Reimbursement Claim Form is available is available at xxxxx://xxxxxxxxxxxxxxxxxxx.xxx/~/media/Files/SHL/pdf/Forms/Pharmacy-Reimbursement- Claim-Form.ashx?la=enxxxx://xxxxxxxxxxxxxxxxxx.xxx/~/media/Files/HPN/pdf/Forms/OptumRx- Reimbursement.ashx?la=en. SHL HPN may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the InsuredMember’s annual CYD and/or Out of Pocket Maximum or to reduce the InsuredMember’s Copayments and/or Coinsurance. Costs defrayed for the Insured Member as a result of pharmaceutical coupons are not Eligible Expenses. Questions regarding which coupons or offers are available can be addressed at xxxxxxxxxxxxxxxxxxx.xxxxxxxxxxxxxxxxxxxxx.xxx. SHL HPN may receive rebates for certain drugs included on the Prescription Drug List, including those drugs that an Insured a Member purchased prior to meeting any applicable deductible. As determined by SHLHPN, a portion of any rebates may be passed on to the Insured Member and may be taken into account in determining any applicable Copayment and/or Cost-share. SHLHPN, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers separate and apart from the Outpatient Prescription Drug benefit. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient Prescription Drug benefit and, therefore, such amounts do not pass on to the InsuredMember.

Coverage Policies and Guidelines. SHLs HPNs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on SHLHPN’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician. When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person is a determination that is made by the Covered Person and the prescribing Physician. NOTE: the tier status of a Prescription Drug may change periodically based on the process described above but only at times specified by NRS 687B.4095 above. As a result of such changes, you may be required to pay more or less for that Prescription Drug. Questions about SHLHPN’s PDL should be directed to the Member Services Department at 0-000-000-0000 or the PDL and the Pharmacy Reimbursement Claim Form is available at xxxxx://xxxxxxxxxxxxxxxxxxx.xxx/~/media/Files/SHL/pdf/Forms/Pharmacy-Reimbursement- Claim-Form.ashx?la=enxxxx://xxx.xxxxxxxxx.xxx/ which leads to HPN’s portal xxx.xxxxxxxxxxx.xxx. SHL  Coupons: HPN may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the InsuredMember’s annual CYD and/or Out of Pocket Maximum or to reduce the InsuredMember’s Copayments and/or Coinsurance. Costs defrayed for the Insured Member as a result of pharmaceutical coupons are not Eligible Expenses. Questions regarding which coupons or offers are available can be addressed at xxxxxxxxxxxxxxxxxxx.xxx. SHL may receive rebates for certain drugs included on the Prescription Drug List, including those drugs that an Insured purchased prior to meeting any applicable deductible. As determined by SHL, a portion of any rebates may be passed on to the Insured and may be taken into account in determining any applicable Copayment and/or Cost-share. SHL, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers separate and apart from the Outpatient Prescription Drug benefit. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient Prescription Drug benefit and, therefore, such amounts do not pass on to the Insuredxxxxxxxxxxx.xxx.

Coverage Policies and Guidelines. SHLs HPNs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on SHLHPN’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including including, but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician. When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons covered persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person covered person is a determination that is made by the Covered Person covered person and the prescribing Physician. NOTE: the tier status of a Prescription Drug may change periodically based on the process described above but only at times specified by NRS 687B.4095 . As a result of such changes, you may be required to pay more or less for that Prescription Drug. Questions about SHLHPN’s PDL should be directed to the Member Services Department at 0-000-000-0000 or the PDL and the Pharmacy Reimbursement Claim Form is available is available at xxxxx://xxxxxxxxxxxxxxxxxxx.xxx/~/media/Files/SHL/pdf/Forms/Pharmacy-Reimbursement- Claim-Form.ashx?la=enxxxx://xxxxxxxxxxxxxxxxxx.xxx/~/media/Files/HPN/pdf/Forms/OptumRx- Reimbursement.ashx?la=en. SHL HPN may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the InsuredMember’s annual CYD and/or Out of Pocket Maximum or to reduce the InsuredMember’s Copayments and/or Coinsurance. Costs defrayed for the Insured Member as a result of pharmaceutical coupons are not Eligible Expenses. Questions regarding which coupons or offers are available can be addressed at xxxxxxxxxxxxxxxxxxx.xxxxxxxxxxxxxx.xxx. SHL HPN may receive rebates for certain drugs included on the Prescription Drug List, including those drugs that an Insured a Member purchased prior to meeting any applicable deductible. As determined by SHLHPN, a portion of any rebates may be passed on to the Insured Member and may be taken into account in determining any applicable Copayment and/or Cost-share. SHLHPN, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers separate and apart from the Outpatient Prescription Drug benefit. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient Prescription Drug benefit and, therefore, such amounts do not pass on to the InsuredMember.

Coverage Policies and Guidelines. SHLs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on SHL’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician. When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person is a determination that is made by the Covered Person and the prescribing Physician. NOTE: the tier status of a Prescription Drug may change periodically based on the process described above but only at times specified by NRS 687B.4095 above. As a result of such changes, you may be required to pay more or less for that Prescription Drug. Questions about SHL’s PDL should be directed to the Member Services Department at 0-000-000-0000 or the PDL and the Pharmacy Reimbursement Claim Form is available at xxxxx://xxxxxxxxxxxxxxxxxxx.xxx/~/media/Files/SHL/pdf/Forms/Pharmacy-Reimbursement- Claim-Form.ashx?la=enxxxx://xxx.xxxxxxxxx.xxx/ which leads to SHL’s portal xxx.xxxxxxxxxxx.xxx. • Coupons: SHL may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the Insured’s annual CYD and/or Out of Pocket Maximum or to reduce the Insured’s Copayments and/or Coinsurance. Costs defrayed for the Insured as a result of pharmaceutical coupons are not Eligible Expenses. Questions regarding which coupons or offers are available can be addressed at xxxxxxxxxxxxxxxxxxx.xxx. SHL may receive rebates for certain drugs included on the Prescription Drug List, including those drugs that an Insured purchased prior to meeting any applicable deductible. As determined by SHL, a portion of any rebates may be passed on to the Insured and may be taken into account in determining any applicable Copayment and/or Cost-share. SHL, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers separate and apart from the Outpatient Prescription Drug benefit. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient Prescription Drug benefit and, therefore, such amounts do not pass on to the Insuredxxxxxxxxxxx.xxx .

Coverage Policies and Guidelines. SHLs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on SHL’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician. When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person is a determination that is made by the Covered Person and the prescribing Physician. NOTE: the tier status of a Prescription Drug may change periodically based on the process described above but only at times specified by NRS 687B.4095 . As a result of such changes, you may be required to pay more or less for that Prescription Drug. Questions about SHL’s PDL should be directed to the Member Services Department at 0-000-000-0000 or the PDL and the Pharmacy Reimbursement Claim Form is available at xxxxx://xxxxxxxxxxxxxxxxxxx.xxx/~/media/Files/SHL/pdf/Forms/Pharmacy-Reimbursement- xxxxx://xxxxxxxxxxxxxxxxxxx.xxx/~/media/Files/HPN/pdf/Forms/Pharmacy-Reimbursement- Claim-Form.ashx?la=en. SHL may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the Insured’s annual CYD and/or Out of Pocket Maximum or to reduce the Insured’s Copayments and/or Coinsurance. Costs defrayed for the Insured as a result of pharmaceutical coupons are not Eligible Expenses. Questions regarding which coupons or offers are available can be addressed at xxxxxxxxxxxxxxxxxxx.xxxxxxxxxxxxxx.xxx. SHL may receive rebates for certain drugs included on the Prescription Drug List, including those drugs that an Insured purchased prior to meeting any applicable deductible. As determined by SHL, a portion of any rebates may be passed on to the Insured and may be taken into account in determining any applicable Copayment and/or Cost-share. SHL, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers separate and apart from the Outpatient Prescription Drug benefit. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient Prescription Drug benefit and, therefore, such amounts do not pass on to the Insured.

Coverage Policies and Guidelines. SHLs HPNs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on SHLHPN’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician. When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person is a determination that is made by the Covered Person and the prescribing Physician. NOTE: the tier status of a Prescription Drug may change periodically based on the process described above but only at times specified by NRS 687B.4095 . As a result of such changes, you may be required to pay more or less for that Prescription Drug. Questions about SHLHPN’s PDL should be directed to the Member Services Department at 0-000-000-0000 or the PDL and the Pharmacy Reimbursement Claim Form is available at xxxxx://xxxxxxxxxxxxxxxxxxx.xxx/~/media/Files/SHL/pdf/Forms/Pharmacy-Reimbursement- Claim-Form.ashx?la=en. SHL may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the Insured’s annual CYD and/or Out of Pocket Maximum or to reduce the Insured’s Copayments and/or Coinsurance. Costs defrayed for the Insured as a result of pharmaceutical coupons are not Eligible Expenses. Questions regarding which coupons or offers are available can be addressed at xxxxxxxxxxxxxxxxxxx.xxx. SHL may receive rebates for certain drugs included on the Prescription Drug List, including those drugs that an Insured purchased prior to meeting any applicable deductible. As determined by SHL, a portion of any rebates may be passed on to the Insured and may be taken into account in determining any applicable Copayment and/or Cost-share. SHL, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers separate and apart from the Outpatient Prescription Drug benefit. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient Prescription Drug benefit and, therefore, such amounts do not pass on to the Insuredxxxx://xxxxxxxxxxxxxxxxxx.xxx/~/media/Files/HPN/pdf/Forms/OptumRx- Reimbursement.ashx?la=en.

Coverage Policies and Guidelines. SHLs HPNs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on SHLHPN’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including including, but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician. When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons covered persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person covered person is a determination that is made by the Covered Person covered person and the prescribing Physician. NOTE: the tier status of a Prescription Drug may change periodically based on the process described above but only at times specified by NRS 687B.4095 . As a result of such changes, you may be required to pay more or less for that Prescription Drug. Questions about SHLHPN’s PDL should be directed to the Member Services Department at 000-000-0000 or the PDL and the Pharmacy Reimbursement Claim Form is available is available at xxxxx://xxxxxxxxxxxxxxxxxxx.xxx/~/media/Files/SHL/pdf/Forms/Pharmacy-Reimbursement- Claim-Form.ashx?la=enxxxx://xxxxxxxxxxxxxxxxxx.xxx/~/media/Files/HPN/pdf/Forms/OptumRx- Reimbursement.ashx?la=en. SHL HPN may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the InsuredMember’s annual CYD and/or Out of Pocket Maximum or to reduce the InsuredMember’s Copayments and/or Coinsurance. Costs defrayed for the Insured Member as a result of pharmaceutical coupons are not Eligible Medical Expenses. Questions regarding which coupons or offers are available can be addressed at xxxxxxxxxxxxxxxxxxx.xxxxxxxxxxxxxxxxxxxxx.xxx. SHL At various times, HPN may send mailings or provide other communications that include a variety of messages, including information about prescription and non-prescription drugs. These communications may include offers that enable the Member to purchase the described product at a discount. In some instances, non-HPN entities may support and/or provide content for these communications and offers. Only the Member and the Provider can determine whether a change in prescription and/or non-prescription drug regimen is appropriate for the Member’s medical condition. Variable Copayment Program: Certain Specialty Prescription Drugs are eligible for coupons or offers from pharmaceutical manufacturers or affiliates that may reduce the cost for the Member’s Prescription Drug and HPN may help the Member determine whether the Specialty Prescription Drug is eligible for this reduction. If the Member redeems a coupon from a pharmaceutical manufacturer or affiliate, the Copayment and/or Coinsurance may vary. Please contact the telephone number on your ID card for an available list of Specialty Prescription Drugs. If the Member chooses not to participate, they will pay the Copayment or Coinsurance as described in the Attachment A Benefit Schedule. The amount of the coupon will not count toward any applicable Calendar Year Deductible or Out of Pocket Maximums. HPN may receive rebates for certain drugs included on the Prescription Drug List, including those drugs that an Insured a Member purchased prior to meeting any applicable deductible. As determined by SHLHPN, a portion of any rebates may be passed on to the Insured Member and may be taken into account in determining any applicable Copayment and/or Cost-share. SHLHPN, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers separate and apart from the Outpatient Prescription Drug benefit. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient Prescription Drug benefit and, therefore, such amounts do not pass on to the InsuredMember.

Coverage Policies and Guidelines. SHLs Our Prescription Drug List (PDL) Management Committee is authorized to make makes tier placement changes on SHL’s our behalf. The PDL Management Committee makes the final classification of an places FDA-approved Prescription Drug to a certain tier Product into tiers by considering a number of factors including but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations include review of the place in therapytherapy or use as compared to other similar product or services, site of care, relative safety or relative efficacy effectiveness of the Prescription DrugDrug Product, as well as whether if certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, include the Prescription Drug’s acquisition Drug Product's total cost including, but not limited to, available including any rebates and assessments evaluations of the cost effectiveness of the Prescription DrugDrug Product. Some Prescription Drugs Drug Products are more cost effective for treating specific indications conditions as compared to others; therefore, a Prescription Drug Product may be listed placed on multiple tiers according to the indication condition for which the Prescription Drug Product was prescribedprescribed to treat, or according to whether it was prescribed by a Specialist PhysicianSpecialist. We may, from time to time, change the placement of a Prescription Drug Product among the tiers. These changes generally will happen quarterly, but no more than six times per calendar year. These changes may happen without prior notice to you. When considering a Prescription Drug Product for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons as a general population. Whether a particular Prescription Drug Product is appropriate for an individual Covered Person you is a determination that is made by the Covered Person you and the your prescribing Physician. NOTE: • Coverage for prescription contraceptive drugs approved by the tier status of a Prescription Food and Drug may change periodically based on Administration. Benefits defined under the process described above but only at times specified by NRS 687B.4095 . As a result of such changes, you may be required to pay more or less for that Prescription Drug. Questions about SHL’s PDL should be directed to the Member Health Resources and Services Department at 000-000-0000 or the PDL and the Pharmacy Reimbursement Claim Form is available at xxxxx://xxxxxxxxxxxxxxxxxxx.xxx/~/media/Files/SHL/pdf/Forms/Pharmacy-Reimbursement- Claim-Form.ashx?la=en. SHL may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the Insured’s annual CYD and/or Out of Pocket Maximum or to reduce the Insured’s Copayments and/or Coinsurance. Costs defrayed for the Insured as a result of pharmaceutical coupons are not Eligible Expenses. Questions regarding which coupons or offers are available can be addressed at xxxxxxxxxxxxxxxxxxx.xxx. SHL may receive rebates for certain drugs included on the Prescription Drug List, including those drugs that an Insured purchased prior to meeting any applicable deductible. As determined by SHL, a portion of any rebates may be passed on to the Insured and may be taken into account in determining any applicable Copayment and/or Cost-share. SHL, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers separate and apart from the Outpatient Prescription Drug benefit. Such business may Administration (HRSA) requirement include, but is may be limited to the full range of FDA approved contraceptive methods without cost sharing. Benefits include at least one form of contraception in each of the methods (currently 18) that the FDA has identified in its current Birth Control Guide. These methods are including, but not limited to, data collectionhormonal methods, consultingsuch as oral contraceptives, educational grants and researchoral medications for emergency contraception. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient • Benefits for Prescription Drug benefit andProducts are available for pharmacotherapy when prescribed by a Physician for tobacco cessation treatment and are limited to: • Two 90-day courses of pharmacotherapy per Covered Person per year. • Initiation of any course of pharmacotherapy will be considered an entire course of pharmacotherapy, therefore, such amounts do not pass on even if a Covered Person discontinues or fails to complete the Insuredcourse.

Coverage Policies and Guidelines. SHLs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on SHL’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician. When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person is a determination that is made by the Covered Person and the prescribing Physician. NOTE: the tier status of a Prescription Drug may change periodically based on the process described above but only at times specified by NRS 687B.4095 . As a result of such changes, you may be required to pay more or less for that Prescription Drug. Questions about SHL’s PDL should be directed to the Member Services Department at 000-000-0000 or the PDL and the Pharmacy Reimbursement Claim Form is available at xxxxx://xxxxxxxxxxxxxxxxxxx.xxx/~/media/Files/SHL/pdf/Forms/Pharmacy-Reimbursement- Claim-Form.ashx?la=en. SHL may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the Insured’s annual CYD and/or Out of Pocket Maximum or to reduce the Insured’s Copayments and/or Coinsurance. Costs defrayed for the Insured as a result of pharmaceutical coupons are not Eligible Medical Expenses. Questions regarding which coupons or offers are available can be addressed at xxxxxxxxxxxxxxxxxxx.xxx. At various times, SHL may send mailings or provide other communications that include a variety of messages, including information about prescription and non-prescription drugs. These communications may include offers that enable the Insured to purchase the described product at a discount. In some instances, non-SHL entities may support and/or provide content for these communications and offers. Only the Insured and the Provider can determine whether a change in prescription and/or non-prescription drug regimen is appropriate for the Insured’s medical condition. Variable Copayment Program: Certain Specialty Prescription Drugs are eligible for coupons or offers from pharmaceutical manufacturers or affiliates that may reduce the cost for the Insured’s Prescription Drug and SHL may help the Insured determine whether the Specialty Prescription Drug is eligible for this reduction. If the Insured redeems a coupon from a pharmaceutical manufacturer or affiliate, the Copayment and/or Coinsurance may vary. Please contact the telephone number on your ID card for an available list of Specialty Prescription Drugs. If the Insured chooses not to participate, they will pay the Copayment or Coinsurance as described in the Attachment A Benefit Schedule. The amount of the coupon will not count toward any applicable Calendar Year Deductible or Out of Pocket Maximums. SHL may receive rebates for certain drugs included on the Prescription Drug List, including those drugs that an Insured purchased prior to meeting any applicable deductible. As determined by SHL, a portion of any rebates may be passed on to the Insured and may be taken into account in determining any applicable Copayment and/or Cost-share. SHL, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers separate and apart from the Outpatient Prescription Drug benefit. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient Prescription Drug benefit and, therefore, such amounts do not pass on to the Insured.

Coverage Policies and Guidelines. SHLs HPNs Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on SHLHPN’s behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug to a certain tier by considering a number of factors including including, but not limited to, clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug, as well as whether certain supply limits or prior authorization requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug’s acquisition cost including, but not limited to, available rebates and assessments of the cost effectiveness of the Prescription Drug. Some Prescription Drugs are more cost effective for specific indications as compared to others; therefore, a Prescription Drug may be listed on multiple tiers according to the indication for which the Prescription Drug was prescribed, or according to whether it was prescribed by a Specialist Physician. When considering a Prescription Drug for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons covered persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person covered person is a determination that is made by the Covered Person covered person and the prescribing Physician. NOTE: the tier status of a Prescription Drug may change periodically based on the process described above but only at times specified by NRS 687B.4095 . As a result of such changes, you may be required to pay more or less for that Prescription Drug. Questions about SHLHPN’s PDL should be directed to the Member Services Department at 000-000-0000 or the PDL and the Pharmacy Reimbursement Claim Form is available is available at xxxxx://xxxxxxxxxxxxxxxxxxx.xxx/~/media/Files/SHL/pdf/Forms/Pharmacy-Reimbursement- Claim-Form.ashx?la=enxxxx://xxxxxxxxxxxxxxxxxx.xxx/~/media/Files/HPN/pdf/Forms/OptumRx- Reimbursement.ashx?la=en. SHL HPN may not permit certain coupons or offers from pharmaceutical manufacturers or their affiliates to apply to the InsuredMember’s annual CYD and/or Out of Pocket Maximum or to reduce the InsuredMember’s Copayments and/or Coinsurance. Costs defrayed for the Insured Member as a result of pharmaceutical coupons are not Eligible Expenses. Questions regarding which coupons or offers are available can be addressed at xxxxxxxxxxxxxxxxxxx.xxx. SHL may receive rebates for certain drugs included on the Prescription Drug List, including those drugs that an Insured purchased prior to meeting any applicable deductible. As determined by SHL, a portion of any rebates may be passed on to the Insured and may be taken into account in determining any applicable Copayment and/or Cost-share. SHL, and a number of our affiliated entities, conduct business with pharmaceutical manufacturers separate and apart from the Outpatient Prescription Drug benefit. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Outpatient Prescription Drug benefit and, therefore, such amounts do not pass on to the Insuredxxxxxxxxxxxxxxxxxx.xxx.