Common use of Drug List Clause in Contracts

Drug List. Drugs listed on the Drug List are selected by the Plan based upon the recom­ mendations of a committee, which is made up of current and previously practicing Physicians and pharmacists from across the country, some of whom are employed by or affiliated with the Plan. The committee considers drugs reg­ ulated by the FDA for inclusion on the Drug List. As part of the process, the committee reviews data from clinical studies, published literature and opinions from experts who are not part of the committee. Some of the factors committee members evaluate include each drug's safety, effectiveness, cost and how it compares with drugs currently on the Drug List. The committee considers drugs that are newly approved by the FDA, as well as those that have been on the market for some time. Entire drug classes are also reg­ ularly reviewed. Changes to this list can be made from time to time. Positive changes, such as adding drugs to the Drug List, occur quarterly after review by our committee. Changes to the Drug List that could have an adverse financial im­ pact to you (e.g., drug exclusion, drugs moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only annually. The Drug List and any modifications will be made available to you. The Plan may offer multiple Drug Lists. By accessing the Plan's website at xxx.xxxxxx.xxx or calling the customer service toll‐free number on your identification card, you will be able to determine the Drug List that applies to you and whether a particular drug is on the Drug List. PRIOR AUTHORIZATION/STEP THERAPY REQUIREMENT Prior Authorization (PA): Your benefit plan requires prior authorization for cer­ tain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications and the request will need to be approved before the medication will be covered under the Plan. You and your Physician will be notified of the prescription drug administrator's determination. If medical ne­ cessity criteria is not met, coverage will be denied and you will be responsible for the full charge incurred.

Drug List. Drugs listed on the Drug List are selected by the Plan based upon the recom­ mendations of a committee, which is made up of current and previously practicing Physicians and pharmacists from across the country, some of whom are employed by or affiliated with the Plan. The committee considers drugs reg­ ulated by the FDA for inclusion on the Drug List. As part of the process, the committee reviews data from clinical studies, published literature and opinions from experts who are not part of the committee. Some of the factors committee members evaluate include each drug's safety, effectiveness, cost and how it compares with drugs currently on the Drug ListList . The committee considers drugs that are newly approved by the FDA, as well as those that have been on the market for some time. Entire drug classes are also reg­ ularly regularly reviewed. Changes to this list can be made from time to time. Positive changes, such as adding drugs to the Drug List, occur quarterly after review by our committee. Changes to the Drug List that could have an adverse financial im­ pact to you (e.g., drug exclusion, drugs moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only annually. The Drug List and any modifications will be made available to you. The Plan may offer multiple Drug Listsformularies. By accessing the Plan's website Web site at xxx.xxxxxx.xxx or calling the customer service Customer Service toll‐free number on your identification card, you will be able to determine the Drug List that applies to you and whether a particular particu­ lar drug is on the Drug ListList . Drugs that appear on the Drug List as Non‐Formulary Brand Name Drugs are subject to the Non‐Formulary Brand Name Drug payment level plus any pricing differences that may apply to the Covered Drug you receive. PRIOR AUTHORIZATION/STEP THERAPY REQUIREMENT Prior Authorization (PA): Your benefit plan requires prior When certain medications and drug classes, such as medications used to treat rheumatoid arthritis, growth hormone deficiency, hepatitis C, and more serious forms of anemia, hypertension, asthma, epilepsy and psoriasis are prescribed, you will be required to obtain authorization from the Plan in order to receive benefits. Medications included in this program are subject to change and other medications for cer­ tain drugsother conditions may be added to the program. This means that Although you may currently be on therapy, your doctor will Claim may need to submit a prior authorization request be reviewed to see if the criteria for coverage of these medications further treatment has been met. A documented treatment with a generic or brand therapeutic alternative medication may be required for continued coverage of the brand name medication. The Plan's prescription drug administrator will send a questionnaire to your Physician upon your or your Pharmacy's request. The questionnaire must be re­ turned to the prescription drug administrator who will review the questionnaire and determine whether the request will need to be approved before reason for the medication will be covered under prescription meets the Plancriteria for medically necessary care. You and your Physician will be notified of the prescription pre­ scription drug administrator's determination. Although there is no penalty if you do not obtain authorization prior to purchasing the medication, you are strongly encouraged to do so, to help you and your doctor factor your cost into your treat­ ment decision. If criteria for medical ne­ cessity criteria necessity is not met, coverage will be denied and you will be responsible for the full charge incurred. To find out more about prior authorization/step therapy requirements or to de­ termine which drugs or drug classes require prior authorization or step therapy, you should contact your Pharmacy or refer to the Drug List by accessing the Web site at xxx.xxxxxx.xxx or call the Customer Service toll‐free number on your identification card.

Drug List. Drugs listed on the Drug List are selected by the Plan based upon the recom­ mendations of a committee, which is made up of current and previously practicing Physicians and pharmacists from across the country, some of whom are employed by or affiliated with the Plan. The committee considers drugs reg­ ulated by the FDA for inclusion on the Drug List. As part of the process, the committee reviews data from clinical studies, published literature and opinions from experts who are not part of the committee. Some of the factors committee members evaluate include each drug's safety, effectiveness, cost and how it compares with drugs currently on the Drug List. The committee considers drugs that are newly approved by the FDA, as well as those that have been on the market for some time. Entire drug classes are also reg­ ularly reviewed. Changes to this list can be made from time to time. Positive changes, such as adding drugs to the Drug List, occur quarterly after review by our committee. Changes to the Drug List that could have an adverse financial im­ pact to you (e.g., drug exclusion, drugs moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only annually. The Drug List and any modifications will be made available to you. The Plan may offer multiple Drug Listsformularies. By accessing the Plan's website at xxx.xxxxxx.xxx or calling the customer service toll‐free number on your identification card, you will be able to determine the Drug List that applies to you and whether a particular drug is on the Drug List. PRIOR AUTHORIZATION/STEP THERAPY REQUIREMENT Prior Authorization (PA): Your benefit plan requires prior authorization for cer­ tain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications and the request will need to be approved before the medication will be covered under the Plan. You and your Physician will be notified of the prescription drug administrator's determination. If medical ne­ cessity criteria is not met, coverage will be denied and you will be responsible for the full charge incurred.

Drug List. Drugs listed on the Drug List are selected by the Plan based upon the recom­ mendations of a committee, which is made up of current and previously practicing Physicians and pharmacists from across the country, some of whom are employed by or affiliated with the Plan. The committee considers drugs reg­ ulated by the FDA for inclusion on the Drug List. As part of the process, the committee commit­ tee reviews data from clinical studies, published literature and opinions from experts who are not part of the committee. Some of the factors committee members mem­ bers evaluate include each drug's safety, effectiveness, cost and how it compares with drugs currently on the Drug List. The committee considers existing drugs that are newly approved by the FDA, as well as those that have been newly FDA approved, for inclusion on the market for some timeDrug List. Entire drug classes are also reg­ ularly regularly reviewed. Changes to this list can be made from time to time. Positive changeschanges (e.g., such as adding drugs to the Drug List, occur drugs moving to a lower payment tier) oc­ cur quarterly after review by our the committee. Changes to the Drug List that could have an adverse financial im­ pact impact to you (e.g., drug exclusion, drugs moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only oc­ cur quarterly or annually. However, when there has been a pharmaceutical manufacturer 's recall or other safety concern, changes to the Drug List may oc­ cur more frequently. The Drug List and any modifications will be made available to you. The Plan may offer multiple Drug Lists. By accessing the Plan's website at xxx.xxxxxx.xxx or calling the customer service toll‐free number on your identification card, you will be able to determine the Drug List that applies to you and whether a particular drug is on the Drug List. PRIOR AUTHORIZATION/STEP THERAPY REQUIREMENT Prior Authorization (PA): Your benefit plan requires prior authorization for cer­ tain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications and the request will need to be approved before the medication will be covered under the Plan. You and your Physician will be notified of the prescription drug administrator's determination. If medical ne­ cessity criteria is not met, coverage will be denied and you will be responsible for the full charge incurred.

Drug List. Drugs listed on the Drug List are selected by the Plan based upon the recom­ recom- mendations of a committee, which is made up of current and previously practicing Physicians and pharmacists from across the country, some of whom are employed by or affiliated with the Plan. The committee considers drugs reg­ reg- ulated by the FDA for inclusion on the Drug List. As part of the process, the committee reviews data from clinical studies, published literature and opinions from experts who are not part of the committee. Some of the factors committee members evaluate include each drug's safety, effectiveness, cost and how it compares with drugs currently on the Drug List. The committee considers drugs that are newly approved by the FDA, as well as those that have been on the market for some time. Entire drug classes are also reg­ reg- ularly reviewed. Changes to this list can be made from time to time. Positive changes, such as adding drugs to the Drug List, occur quarterly after review by our committee. Changes to the Drug List that could have an adverse financial im­ im- pact to you (e.g., drug exclusion, drugs moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only annually. The Drug List and any modifications will be made available to you. The Plan may offer multiple Drug Lists. By accessing the Plan's website at xxx.xxxxxx.xxx or calling the customer service toll‐free number on your identification card, you will be able to determine the Drug List that applies to you and whether a particular drug is on the Drug List. PRIOR AUTHORIZATION/STEP THERAPY REQUIREMENT Prior Authorization (PA): Your benefit plan requires prior authorization for cer­ cer- tain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications and the request will need to be approved before the medication will be covered under the Plan. You and your Physician will be notified of the prescription drug administrator's determination. If medical ne­ ne- cessity criteria is not met, coverage will be denied and you will be responsible for the full charge incurred.

Drug List. Drugs listed on the Drug List are selected by the Plan based upon the recom­ mendations recommend- ations of a committee, which is made up of current and previously practicing Physicians and pharmacists from across the country, some of whom are employed by or affiliated with the Plan. The committee considers drugs reg­ ulated regulated by the FDA for inclusion on the Drug List. As part of the process, the committee reviews data from clinical studies, published literature and opinions from experts who are not part of the committee. Some of the factors committee members evaluate include in- clude each drug's safety, effectiveness, cost and how it compares with drugs currently on the Drug List. The committee considers drugs that are newly approved by the FDA, as well as those that have been on the market for some time. Entire drug classes are also reg­ reg- ularly reviewed. Changes to this list can be made from time to time. Positive changes, such as adding drugs to the Drug List, occur quarterly after review by our committee. Changes to the Drug List that could have an adverse financial im­ pact to you (e.g., drug exclusion, drugs moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only annually. The Drug List and any modifications will be made available to you. The Plan may offer multiple Drug Listsformularies. By accessing the Plan's website Web site at xxx.xxxxxx.xxx or calling call- ing the customer service Customer Service toll‐free number on your identification card, you will be able to determine the Drug List that applies to you and whether a particular drug is on the Drug List. Drugs that appear on the Drug List as Non‐Formulary Brand Name Drugs are subject to the Non‐Formulary Brand Name Drug payment level plus any pricing differences that may apply to the Covered Drug you receive. You, your prescribing health care Provider, or your authorized representative, can ask for a Drug List exception if your drug is not on (or is being removed from) the Drug List (also known as a Formulary), or the drug required as part of step therapy or dispensing limits has been found to be (or likely to be) not right for you or does not work as well in treating your condition. To request this exception, you, your prescribing Provider, or your authorized representative, can call the number on the back of your ID card to ask for a review. The Plan will let you, your pre- scribing Provider (or authorized representative) know the coverage decision within 72 hours after they receive your request. If the coverage request is denied, the Plan will let you and your prescribing Provider (or authorized representative) know why it was denied and offer you a covered alternative drug (if applicable). If your exception is denied, you may appeal the decision according to the appeals process you will receive with the denial determination. If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current drug therapy uses a non-covered drug, you, your prescribing Provider, or your authorized representative, may be able to ask for an expedited review process. The Plan will let you, your prescribing Pro- vider (or authorized representative) know the coverage decision within 24 hours after they receive your request for an expedited review. If the coverage request is denied, the Plan will let you and your prescribing Provider (or authorized rep- resentative) know why it was denied and offer you a covered alternative drug (if applicable). If your exception is denied, you may appeal the decision according to the appeals process you will receive with the denial determination. Call the number on the back of your ID card if you have any questions. PRIOR AUTHORIZATION/STEP THERAPY REQUIREMENT Prior Authorization (PA): Your benefit plan requires prior authorization for cer­ tain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these When certain medications and drug classes, such as medications used to treat rheumatoid arthritis, growth hormone deficiency, hepatitis C, and more serious forms of anemia, hypertension, asthma, epilepsy and psoriasis are prescribed, you will be required to obtain authorization from the request will Plan in order to receive benefits. Medications included in this program are subject to change and other medications for other conditions may be added to the program. Although you may currently be on therapy, your Claim may need to be approved before reviewed to see if the criteria for cover- age of further treatment has been met. A documented treatment with a generic or brand therapeutic alternative medication may be required for continued coverage of the brand name medication. The Plan's prescription drug administrator will send a questionnaire to your Phys- ician upon your or your Pharmacy's request. The questionnaire must be covered under returned to the Planprescription drug administrator who will review the questionnaire and xx- xxxxxxx whether the reason for the prescription meets the criteria for medically necessary care. You and your Physician will be notified of the prescription drug administratoradministrator 's determination. Although there is no penalty if you do not obtain authorization prior to purchasing the medication, you are strongly encouraged to do so, to help you and your doctor factor your cost into your treatment decision. If criteria for medical ne­ cessity criteria necessity is not met, coverage will be denied and you will be responsible for the full charge incurred. To find out more about prior authorization/step therapy requirements or to xx- xxxxxxx which drugs or drug classes require prior authorization or step therapy, you should contact your Pharmacy or refer to the Drug List by accessing the Web site at xxx.xxxxxx.xxx or call the Customer Service toll‐free number on your identification card.

Drug List. Drugs listed on the Drug List are selected by the Plan based upon the recom­ recom- mendations of a committee, which is made up of current and previously practicing Physicians and pharmacists from across the country, some of whom are employed by or affiliated with the Plan. The committee considers drugs reg­ reg- ulated by the FDA for inclusion on the Drug List. As part of the process, the committee reviews data from clinical studies, published literature and opinions from experts who are not part of the committee. Some of the factors committee members evaluate include each drug's safety, effectiveness, cost and how it compares with drugs currently on the Drug ListList . The committee considers drugs that are newly approved by the FDA, as well as those that have been on the market for some time. Entire drug classes are also reg­ ularly regularly reviewed. Changes to this list can be made from time to time. Positive changes, such as adding drugs to the Drug List, occur quarterly after review by our committee. Changes to the Drug List that could have an adverse financial im­ pact to you (e.g., drug exclusion, drugs moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only annually. The Drug List and any modifications will be made available to you. The Plan may offer multiple Drug Listsformularies. By accessing the Plan's website Web site at xxx.xxxxxx.xxx or calling the customer service Customer Service toll‐free number on your identification card, you will be able to determine the Drug List that applies to you and whether a particular particu- lar drug is on the Drug ListList . Drugs that appear on the Drug List as Non‐Formulary Brand Name Drugs are subject to the Non‐Formulary Brand Name Drug payment level plus any pricing differences that may apply to the Covered Drug you receive. GB‐16 HCSC 61 PRIOR AUTHORIZATION/STEP THERAPY REQUIREMENT Prior Authorization (PA): Your benefit plan requires prior When certain medications and drug classes, such as medications used to treat rheumatoid arthritis, growth hormone deficiency, hepatitis C, and more serious forms of anemia, hypertension, asthma, epilepsy and psoriasis are prescribed, you will be required to obtain authorization from the Plan in order to receive benefits. Medications included in this program are subject to change and other medications for cer­ tain drugsother conditions may be added to the program. This means that Although you may currently be on therapy, your doctor will Claim may need to submit a prior authorization request be reviewed to see if the criteria for coverage of these medications further treatment has been met. A documented treatment with a generic or brand therapeutic alternative medication may be required for continued coverage of the brand name medication. The Plan's prescription drug administrator will send a questionnaire to your Physician upon your or your Pharmacy's request. The questionnaire must be re- turned to the prescription drug administrator who will review the questionnaire and determine whether the request will need to be approved before reason for the medication will be covered under prescription meets the Plancriteria for medically necessary care. You and your Physician will be notified of the prescription pre- scription drug administrator's determination. Although there is no penalty if you do not obtain authorization prior to purchasing the medication, you are strongly encouraged to do so, to help you and your doctor factor your cost into your treat- ment decision. If criteria for medical ne­ cessity criteria necessity is not met, coverage will be denied and you will be responsible for the full charge incurred. To find out more about prior authorization/step therapy requirements or to xx- xxxxxxx which drugs or drug classes require prior authorization or step therapy, you should contact your Pharmacy or refer to the Drug List by accessing the Web site at xxx.xxxxxx.xxx or call the Customer Service toll‐free number on your identification card.

Drug List. Drugs listed on the Drug List are selected by the Plan based upon the recom­ mendations recommend­ ations of a committee, which is made up of current and previously practicing Physicians and pharmacists from across the country, some of whom are employed by or affiliated with the Plan. The committee considers drugs reg­ ulated regulated by the FDA for inclusion on the Drug List. As part of the process, the committee reviews data from clinical studies, published literature and opinions from experts who are not part of the committee. Some of the factors committee members evaluate include in­ clude each drug's safety, effectiveness, cost and how it compares with drugs currently on the Drug List. The committee considers drugs that are newly approved by the FDA, as well as those that have been on the market for some time. Entire drug classes are also reg­ ularly reviewed. Changes to this list can be made from time to time. Positive changes, such as adding drugs to the Drug List, occur quarterly after review by our committee. Changes to the Drug List that could have an adverse financial im­ pact to you (e.g., drug exclusion, drugs moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only annually. The Drug List and any modifications will be made available to you. The Plan may offer multiple Drug Listsformularies. By accessing the Plan's website Web site at xxx.xxxxxx.xxx or calling call­ ing the customer service toll‐free number on your identification card, you will be able to determine the Drug List that applies to you and whether a particular drug is on the Drug List. Drugs that appear on the Drug List as Non‐Formulary Brand Name Drugs are subject to the Non‐Formulary Brand Name Drug payment level plus any pricing differences that may apply to the Covered Drug you receive. You, your prescribing health care Provider, or your authorized representative, can ask for a Drug List exception if your drug is not on (or is being removed from) the Drug List (also known as a Formulary), or the drug required as part of step IL‐G‐H‐OF‐2016 67 therapy or dispensing limits has been found to be (or likely to be) not right for you or does not work as well in treating your condition. To request this exception, you, your prescribing Provider, or your authorized representative, can call the number on the back of your ID card to ask for a review. The Plan will let you, your pre­ scribing Provider (or authorized representative) know the coverage decision within 72 hours after they receive your request. If the coverage request is denied, the Plan will let you and your prescribing Provider (or authorized representative) know why it was denied and offer you a covered alternative drug (if applicable). If your exception is denied, you may appeal the decision according to the appeals process you will receive with the denial determination. If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current drug therapy uses a non‐covered drug, you, your prescribing Provider, or your authorized representative, may be able to ask for an expedited review process. The Plan will let you, your prescribing Pro­ vider (or authorized representative) know the coverage decision within 24 hours after they receive your request for an expedited review. If the coverage request is denied, the Plan will let you and your prescribing Provider (or authorized rep­ resentative) know why it was denied and offer you a covered alternative drug (if applicable). If your exception is denied, you may appeal the decision according to the appeals process you will receive with the denial determination. Call the number on the back of your ID card if you have any questions. PRIOR AUTHORIZATION/STEP THERAPY REQUIREMENT Prior Authorization (PA): Your benefit plan requires prior authorization for cer­ tain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these When certain medications and drug classes, such as medications used to treat rheumatoid arthritis, growth hormone deficiency, hepatitis C, and more serious forms of anemia, hypertension, asthma, epilepsy and psoriasis are prescribed, you will be required to obtain authorization from the request will Plan in order to receive benefits. Medications included in this program are subject to change and other medications for other conditions may be added to the program. Although you may currently be on therapy, your Claim may need to be approved before reviewed to see if the criteria for cover­ age of further treatment has been met. A documented treatment with a generic or brand therapeutic alternative medication may be required for continued coverage of the brand name medication. The Plan's prescription drug administrator will send a questionnaire to your Phy­ sician upon your or your Pharmacy's request. The questionnaire must be covered under returned to the Planprescription drug administrator who will review the questionnaire and de­ termine whether the reason for the prescription meets the criteria for medically necessary care. You and your Physician will be notified of the prescription drug administratoradministrator 's determination. Although there is no penalty if you do not obtain authorization prior to purchasing the medication, you are strongly encouraged to do so, to help you and your doctor factor your cost into your treatment decision. If criteria for medical ne­ cessity criteria necessity is not met, coverage will be denied and you will be responsible for the full charge incurred. To find out more about prior authorization/step therapy requirements or to de­ termine which drugs or drug classes require prior authorization or step therapy, IL‐G‐H‐OF‐2016 68 you should contact your Pharmacy or refer to the Drug List by accessing the Web site at xxx.xxxxxx.xxx or call the customer service toll‐free number on your identification card.

Drug List. Drugs listed on the Drug List are selected by the Plan based upon the recom­ recom- mendations of a committee, which is made up of current and previously practicing Physicians and pharmacists from across the country, some of whom are employed by or affiliated with the Plan. The committee considers drugs reg­ reg- ulated by the FDA for inclusion on the Drug List. As part of the process, the committee reviews data from clinical studies, published literature and opinions from experts who are not part of the committee. Some of the factors committee members evaluate include each drug's safety, effectiveness, cost and how it compares with drugs currently on the Drug ListList . The committee considers drugs that are newly approved by the FDA, as well as those that have been on the market for some time. Entire drug classes are also reg­ ularly regularly reviewed. Changes to this list can be made from time to time. Positive changes, such as adding drugs to the Drug List, occur quarterly after review by our committee. Changes to the Drug List that could have an adverse financial im­ pact to you (e.g., drug exclusion, drugs moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only annually. The Drug List and any modifications will be made available to you. The Plan may offer multiple Drug Listsformularies. By accessing the Plan's website Web site at xxx.xxxxxx.xxx or calling the customer service Customer Service toll‐free number on your identification card, you will be able to determine the Drug List that applies to you and whether a particular particu- lar drug is on the Drug ListList . Drugs that appear on the Drug List as Non‐Formulary Brand Name Drugs are subject to the Non‐Formulary Brand Name Drug payment level plus any pricing differences that may apply to the Covered Drug you receive. PRIOR AUTHORIZATION/STEP THERAPY REQUIREMENT Prior Authorization (PA): Your benefit plan requires prior When certain medications and drug classes, such as medications used to treat rheumatoid arthritis, growth hormone deficiency, hepatitis C, and more serious forms of anemia, hypertension, asthma, epilepsy and psoriasis are prescribed, you will be required to obtain authorization from the Plan in order to receive benefits. Medications included in this program are subject to change and other medications for cer­ tain drugsother conditions may be added to the program. This means that Although you may currently be on therapy, your doctor will Claim may need to submit a prior authorization request be reviewed to see if the criteria for coverage of these medications further treatment has been met. A documented treatment with a generic or brand therapeutic alternative medication may be required for continued coverage of the brand name medication. The Plan's prescription drug administrator will send a questionnaire to your Physician upon your or your Pharmacy's request. The questionnaire must be re- turned to the prescription drug administrator who will review the questionnaire and determine whether the request will need to be approved before reason for the medication will be covered under prescription meets the Plancriteria for medically necessary care. You and your Physician will be notified of the prescription pre- scription drug administrator's determination. Although there is no penalty if you do not obtain authorization prior to purchasing the medication, you are strongly encouraged to do so, to help you and your doctor factor your cost into your treat- ment decision. If criteria for medical ne­ cessity criteria necessity is not met, coverage will be denied and you will be responsible for the full charge incurred. To find out more about prior authorization/step therapy requirements or to xx- xxxxxxx which drugs or drug classes require prior authorization or step therapy, you should contact your Pharmacy or refer to the Drug List by accessing the Web site at xxx.xxxxxx.xxx or call the Customer Service toll‐free number on your identification card.

Drug List. Drugs listed on the Drug List are selected by the Plan based upon the recom­ mendations of a committee, which is made up of current and previously practicing Physicians and pharmacists from across the country, some of whom are employed by or affiliated with the Plan. The committee considers drugs reg­ ulated by the FDA for inclusion on the Drug List. As part of the process, the committee reviews data from clinical studies, published literature and opinions from experts who are not part of the committee. Some of the factors committee members evaluate include each drug's safety, effectiveness, cost and how it compares with drugs currently on the Drug List. The committee considers drugs that are newly approved by the FDA, as well as those that have been on the market for some time. Entire drug classes are also reg­ ularly regularly reviewed. Changes to this list can be made from time to time. Positive changes, such as adding drugs to the Drug List, occur quarterly after review by our committee. Changes to the Drug List that could have an adverse financial im­ pact to you (e.g., drug exclusion, drugs moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only annually. The Drug List and any modifications will be made available to you. The Plan may offer multiple Drug Listsformularies. By accessing the Plan's website Web site at xxx.xxxxxx.xxx or calling the customer service Customer Service toll‐free number on your identification card, you will be able to determine the Drug List that applies to you and whether a particular particu­ lar drug is on the Drug ListList . Drugs that appear on the Drug List as Non‐Formulary Brand Name Drugs are subject to the Non‐Formulary Brand Name Drug payment level plus any pricing differences that may apply to the Covered Drug you receive. PRIOR AUTHORIZATION/STEP THERAPY REQUIREMENT Prior Authorization (PA): Your benefit plan requires prior When certain medications and drug classes, such as medications used to treat rheumatoid arthritis, growth hormone deficiency, hepatitis C, and more serious forms of anemia, hypertension, asthma, epilepsy and psoriasis are prescribed, you will be required to obtain authorization from the Plan in order to receive benefits. Medications included in this program are subject to change and other medications for cer­ tain drugsother conditions may be added to the program. This means that Although you may currently be on therapy, your doctor will Claim may need to submit a prior authorization request be reviewed to see if the criteria for coverage of these medications further treatment has been met. A documented treatment with a generic or brand therapeutic alternative medication may be required for continued coverage of the brand name medication. The Plan's prescription drug administrator will send a questionnaire to your Physician upon your or your Pharmacy's request. The questionnaire must be re­ turned to the prescription drug administrator who will review the questionnaire and determine whether the request will need to be approved before reason for the medication will be covered under prescription meets the Plancriteria for medically necessary care. You and your Physician will be notified of the prescription pre­ scription drug administrator's determination. Although there is no penalty if you do not obtain authorization prior to purchasing the medication, you are strongly encouraged to do so, to help you and your doctor factor your cost into your treat­ ment decision. If criteria for medical ne­ cessity criteria necessity is not met, coverage will be denied and you will be responsible for the full charge incurred. To find out more about prior authorization/step therapy requirements or to de­ termine which drugs or drug classes require prior authorization or step therapy, you should contact your Pharmacy or refer to the Drug List by accessing the Web site at xxx.xxxxxx.xxx or call the Customer Service toll‐free number on your identification card.

Drug List. Drugs listed on the Drug List are selected by the Plan based upon the recom­ mendations recommendations of a committee, which is made up of current and previously practicing Physicians and pharmacists from across the country, some of whom are employed by or affiliated with the Plan. The committee considers drugs reg­ ulated by the FDA for inclusion on the Drug List. As part of the process, the committee reviews data from clinical studies, published literature and opinions from experts who are not part of the committee. Some of the factors committee members evaluate include each drug's safety, effectiveness, cost and how it compares with drugs currently on the Drug List. The committee considers existing drugs that are newly approved by the FDA, as well as those that have been newly FDA approved, for inclusion on the market for some timeDrug List. Entire drug classes are also reg­ ularly regularly reviewed. Changes to this list can be made from time to time. Positive changeschanges (e.g., such as adding drugs to the Drug List, drugs moving to a lower payment tier) occur quarterly after review by our the committee. Changes to the Drug List that could have an adverse financial im­ pact impact to you (e.g., drug exclusion, drugs moving to a higher payment tier, or drugs requiring step therapy or prior authorization) occur only quarterly or annually. However, when there has been a pharmaceutical manufacturer's recall or other safety concern, changes to the Drug List may occur more frequently. The Drug List and any modifications will be made available to you. The Plan may offer multiple Drug Lists. By accessing the Plan's website at xxx.xxxxxx.xxx or calling the customer service toll‐free number on your identification card, you will be able to determine the Drug List that applies to you and whether a particular drug is on the Drug List. PRIOR AUTHORIZATION/STEP THERAPY REQUIREMENT Prior Authorization (PA): Your benefit plan requires prior authorization for cer­ tain certain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications and the request will need to be approved before the medication will be covered under the Plan. You and your Physician will be notified of the prescription drug administrator's determination. If medical ne­ cessity necessity criteria is not met, coverage will be denied and you will be responsible for the full charge incurred.