Common use of Covered Prescription Drugs Clause in Contracts

Covered Prescription Drugs. We cover Medically Necessary Prescription Drugs that, except as specifically provided otherwise, can be dispensed only pursuant to a prescription and are: • Not Experimental/Investigative; • Determined by Us to be appropriate in quantity; • Determined by Us to be appropriate for Your age; • Required by law to bear the legend “Caution – Federal Law prohibits dispensing without a prescription”; • FDA approved; • Ordered by a Provider authorized to prescribe and within the Provider’s scope of practice; • Prescribed within the approved FDA administration and dosing guidelines; and • Dispensed by a licensed, Network Pharmacy. • Covered Prescription Drugs Benefits include but are not limited to the following: • Prescription Legend Drugs • Specialty Drugs • Injectable insulin and syringes used for administration of insulin. • Oral contraceptive Drugs, injectable contraceptive drugs and patches are covered when obtained through an eligible Pharmacy. Certain contraceptives are covered under the “Preventive Care” benefit. Please see that section for further details. • Injectables • Off label use, unless approved by Us or the PBM or when the drug has been recognized as safe and effective for treatment of that indication in one or more of the standard medical reference compendia adopted by the United States Department of Health and Human Services or in medical literature that meets certain criteria. Medical literature may be accepted only if all of the following apply:

Covered Prescription Drugs. We cover Medically Necessary Prescription Drugs that, except as specifically provided otherwise, can be dispensed only pursuant to a prescription and are: • Not Experimental/Investigative; • Determined by Us to be appropriate in quantity; • Determined by Us to be appropriate for Your age; • Required by law to bear the legend “Caution – Federal Law prohibits dispensing without a prescription”; • FDA approved; • Ordered by a Provider authorized to prescribe and within the Provider’s scope of practice; • Prescribed within the approved FDA administration and dosing guidelines; and • Dispensed by a licensed, Network Pharmacy. • Covered Prescription Drugs Benefits include but are not limited to the following: • Prescription Legend Drugs Drugs. • Specialty Drugs Drugs. • Injectable insulin and syringes used for administration of insulin. • Oral contraceptive Drugs, injectable contraceptive drugs and patches are covered when obtained through an eligible Pharmacy. Certain contraceptives are covered under the “Preventive Care” benefit. Please see that section for further details. • Injectables • Off label use, unless approved by Us or the PBM or when the drug has been recognized as safe and effective for treatment of that indication in one or more of the standard medical reference compendia adopted by the United States Department of Health and Human Services or in medical literature that meets certain criteria. Medical literature may be accepted only if all of the following apply:.