Common use of Eligible PS Clause in Contracts

Eligible PS. T Unit employees enrolled in the Empire Plan will be provided with prescription drug coverage through the Empire Plan Prescription Drug Program. The benefits provided shall consist of the following: The Prescription Drug Program will cover medically necessary drugs requiring a physician’s prescription and dispensed by a licensed pharmacist. Mandatory Generic Substitution will be required for all brand-name multi-source prescription drugs (a brand-name drug with a generic equivalent) covered by the Prescription Drug Program. When a brand-name multi-source drug is dispensed, the Program will reimburse the pharmacy (or enrollee) for the cost of the drug’s generic equivalent. The enrollee is responsible for the cost difference between the brand-name drug and its generic equivalent, plus the copayment. The enrollee is responsible for the cost difference between the non-preferred brand name drug and its generic equivalent (ancillary charge), plus the copayment for the non-preferred brand name drug. • The copayment for up to a 30-day supply at either the retail, specialty or mail service pharmacy will be $5 for generic/Level One drugs, $30 for preferred brand/Level Two drugs and $60 for non-preferred brand/Level Three drugs. • The copayment for a 31 to 90 day supply at the retail or specialty pharmacy will be $10 for generic/Level One drugs, $60 for preferred brand/Level Two drugs and $120 for non- preferred brand/Level Three drugs. • The copayment for a 31 to 90 day supply at the mail service pharmacy will be $5 for ge- neric/Level One drugs, $55 for preferred brand/Level Two drugs and $110 for non-pre- ferred brand/Level Three drugs. • Prescription drugs will be dispensed through either the preferred provider community pharmacy network (retail pharmacy), or the mail service pharmacy. • Coverage will be provided under the Empire Plan Prescription Drug Program for pre- scription vitamins, contraceptive drugs, and contraceptive devices purchased at a phar- macy. * A medical exception program is available for non-formulary prescription drugs that are excluded from coverage. If a physician’s request for a medical exception is approved, the Level One copayment will apply for generic drugs and the Level Three copayment will apply for brand-name drugs. * A Dispense as Written exception request is available for medically necessary prescription non-preferred brand-name drugs that have a generic equivalent. If a physician’s request for medical necessity is approved, the Level Three copayment is charged, but the member will not be responsible for the difference in cost between the generic drug and the non-preferred brand-name drug (ancillary charge). * Annual changes may be made to the Advanced Flexible Formulary once a year on January 1st. Such changes may include moving drugs to a higher or lower level, and coverage of previously excluded drugs. Access to one or more drugs in select therapeutic categories may be excluded if the drugs have no clinical advantage over other generic or brand names drugs in the same therapeutic class. Drugs considered to have no clinical advantage that may be excluded include any products that:

Eligible PS. T Unit employees enrolled in the Empire Plan will be provided with prescription drug coverage through the Empire Plan Prescription Drug Program. The benefits provided shall consist of the following: The Prescription Drug Program will cover medically necessary drugs requiring a physician’s prescription and dispensed by a licensed pharmacist. Mandatory Generic Substitution will be required for all brand-name multi-source prescription drugs (a brand-name drug with a generic equivalent) covered by the Prescription Drug Program. When a brand-name multi-source drug is dispensed, the Program will reimburse the pharmacy (or enrollee) for the cost of the drug’s generic equivalent. The enrollee is responsible for the cost difference between the brand-name drug and its generic equivalent, plus the copayment. The enrollee is responsible for the cost difference between the non-preferred brand name drug and its generic equivalent (ancillary charge)equivalent, plus the copayment for the non-preferred brand name drug. • The copayment for up to a 30 day supply at either the retail or mail service pharmacy, will be $5 for generic/Level One drugs $25, for preferred brand/Level Two drugs and $45 for non-preferred brand/Level Three drugs. Effective January 1, 2022, the copayment for up to a 30-day supply at either the retail, specialty retail or mail service pharmacy will be $5 for generic/Level One drugs, $30 for preferred brand/Level Two drugs and $60 for non-non- preferred brand/Level Three drugs. • The copayment for a 31 to 90 day supply at the retail or specialty pharmacy will be $10 for generic/Level One drugs, $50 for preferred brand/Level Two drugs and $90 for non- preferred brand/Level Three drugs. Effective January 1, 2022, the copayment for a 31 to 90 day supply at the retail pharmacy will be $10 for generic/Level One drugs, $60 for preferred brand/Level Two drugs and $120 for non- non-preferred brand/Level Three drugs. • The copayment for a 31 to 90 day supply at the mail service pharmacy will be $5 for ge- nericgeneric/Level One drugs, $50 for preferred brand/Level Two drugs and $90 for non- preferred brand/Level Three drugs. Effective January 1, 2022, the copayment for a 31 to 90 day supply at the mail service pharmacy will be $5 for generic/Level One drugs, $55 for preferred brand/Level Two drugs and $110 for non-pre- ferred preferred brand/Level Three drugs. • Prescription drugs will be dispensed through either the preferred provider community pharmacy network (retail pharmacy), or the mail service pharmacy. • Coverage will be provided under the Empire Plan Prescription Drug Program for pre- scription prescription vitamins, contraceptive drugs, and contraceptive devices purchased at a phar- macy. * A medical exception program is available for non-formulary prescription drugs that are excluded from coverage. If a physician’s request for a medical exception is approved, the Level One copayment will apply for generic drugs and the Level Three copayment will apply for brand-name drugs. * A Dispense as Written exception request is available for medically necessary prescription non-preferred brand-name drugs that have a generic equivalent. If a physician’s request for medical necessity is approved, the Level Three copayment is charged, but the member will not be responsible for the difference in cost between the generic drug and the non-preferred brand-name drug (ancillary charge). * Annual changes may be made to the Advanced Flexible Formulary once a year on January 1st. Such changes may include moving drugs to a higher or lower level, and coverage of previously excluded drugs. Access to one or more drugs in select therapeutic categories may be excluded if the drugs have no clinical advantage over other generic or brand names drugs in the same therapeutic class. Drugs considered to have no clinical advantage that may be excluded include any products that:pharmacy.

Eligible PS. T Unit employees enrolled in the Empire Plan will be provided with prescription drug coverage through the Empire Plan Prescription Drug Program. The benefits provided shall consist of the following: The Prescription Drug Program will cover medically necessary drugs requiring a physician’s prescription and dispensed by a licensed pharmacist. Mandatory Generic Substitution will be required for all brand-name multi-source prescription drugs (a brand-name drug with a generic equivalent) covered by the Prescription Drug Program. When a brand-name multi-source drug is dispensed, the Program will reimburse the pharmacy (or enrollee) for the cost of the drug’s generic equivalent. The enrollee is responsible for the cost difference between the brand-name drug and its generic equivalent, plus the copayment. The enrollee is responsible for the cost difference between the non-preferred brand name drug and its generic equivalent (ancillary charge)equivalent, plus the copayment for the non-preferred brand name drug. •  The copayment for up to a 30-30 day supply at either the retail, specialty retail or mail service pharmacy pharmacy, will be $5 for generic/Level One drugs, $30 25 for preferred brand/Level Two drugs and $60 45 for non-preferred brand/Level Three drugs. •  The copayment for a 31 to 90 day supply at the retail or specialty pharmacy will be $10 for generic/Level One drugs, $60 50 for preferred brand/Level Two drugs and $120 90 for non- preferred brand/Level Three drugs. •  The copayment for a 31 to 90 day supply at the mail service pharmacy will be $5 for ge- nericgeneric/Level One drugs, $55 50 for preferred brand/Level Two drugs and $110 90 for non-pre- ferred non- preferred brand/Level Three drugs. • Prescription drugs will be dispensed through either the preferred provider community pharmacy network (retail pharmacy), or the mail service pharmacy. • Coverage will be provided under the Empire Plan Prescription Drug Program for pre- scription prescription vitamins, contraceptive drugs, and contraceptive devices purchased at a phar- macypharmacy. * A medical exception program is available for non-formulary prescription drugs that are excluded from coverage. If “New to You” prescriptions will require two 30 day fills at a physician’s request for retail pharmacy prior to being able to obtain a medical exception is approved, the Level One copayment will apply for generic drugs and the Level Three copayment will apply for brand-name drugs. * A Dispense as Written exception request is available for medically necessary prescription non-preferred brand-name drugs that have 90 day fill through either a generic equivalent. If a physician’s request for medical necessity is approved, the Level Three copayment is charged, but the member will not be responsible for the difference in cost between the generic drug and the non-preferred brand-name drug (ancillary charge). * Annual changes may be made to the Advanced Flexible Formulary once a year on January 1st. Such changes may include moving drugs to a higher retail or lower level, and coverage of previously excluded drugs. Access to one or more drugs in select therapeutic categories may be excluded if the drugs have no clinical advantage over other generic or brand names drugs in the same therapeutic class. Drugs considered to have no clinical advantage that may be excluded include any products that:mail pharmacy.

Eligible PS. T Unit employees enrolled in the Empire Plan will be provided with prescription drug coverage through the Empire Plan Prescription Drug Program. The benefits provided shall consist of the following: The Prescription Drug Program will cover medically necessary drugs requiring a physician’s prescription and dispensed by a licensed pharmacist. Mandatory Generic Substitution will be required for all brand-name multi-source prescription drugs (a brand-name drug with a generic equivalent) covered by the Prescription Drug Program. When a brand-name multi-source drug is dispensed, the Program will reimburse the pharmacy (or enrollee) for the cost of the drug’s generic equivalent. The enrollee is responsible for the cost difference between the brand-name drug and its generic equivalent, plus the copayment. The enrollee is responsible for the cost difference between the non-preferred brand name drug and its generic equivalent (ancillary charge)equivalent, plus the copayment for the non-preferred brand name drug. drug.‌ • The copayment for up to a 30-30 day supply at either the retail, specialty retail or mail service pharmacy will be $5 for generic/Level One drugs, $30 25 for preferred brand/Level Two drugs and $60 45 for non-preferred brand/Level Three drugs. • The copayment for a 31 to 90 day supply at the retail or specialty pharmacy will be $10 for generic/Level One drugs, $60 50 for preferred brand/Level Two drugs and $120 90 for non- preferred brand/Level Three drugs. • The copayment for a 31 to 90 day supply at the mail service pharmacy will be $5 for ge- nericgeneric/Level One drugs, $55 50 for preferred brand/Level Two drugs and $110 90 for non-pre- ferred non- preferred brand/Level Three drugs. • Prescription drugs will be dispensed through either the preferred provider community pharmacy network (retail pharmacy), or the mail service pharmacy. • Coverage will be provided under the Empire Plan Prescription Drug Program for pre- scription prescription vitamins, contraceptive drugs, and contraceptive devices purchased at a phar- macypharmacy. * A medical exception program is available for non-formulary prescription drugs that are excluded from coverage. If “New to You” prescriptions will require two 30 day fills at a physician’s request for retail pharmacy prior to being able to obtain a medical exception is approved, the Level One copayment will apply for generic drugs and the Level Three copayment will apply for brand-name drugs. * A Dispense as Written exception request is available for medically necessary prescription non-preferred brand-name drugs that have 90 day fill through either a generic equivalent. If a physician’s request for medical necessity is approved, the Level Three copayment is charged, but the member will not be responsible for the difference in cost between the generic drug and the non-preferred brand-name drug (ancillary charge). * Annual changes may be made to the Advanced Flexible Formulary once a year on January 1st. Such changes may include moving drugs to a higher retail or lower level, and coverage of previously excluded drugs. Access to one or more drugs in select therapeutic categories may be excluded if the drugs have no clinical advantage over other generic or brand names drugs in the same therapeutic class. Drugs considered to have no clinical advantage that may be excluded include any products that:mail pharmacy.

Eligible PS. T Unit employees enrolled in the Empire Plan will be provided with prescription drug coverage through the Empire Plan Prescription Drug Program. The benefits provided shall consist of the following: The Prescription Drug Program will cover medically necessary drugs requiring a physician’s prescription and dispensed by a licensed pharmacist. Mandatory Generic Substitution will be required for all brand-name multi-source prescription drugs (a brand-name drug with a generic equivalent) covered by the Prescription Drug Program. When a brand-name multi-source drug is dispensed, the Program will reimburse the pharmacy (or enrollee) for the cost of the drug’s generic equivalent. The enrollee is responsible for the cost difference between the brand-name drug and its generic equivalent, plus the copayment. The enrollee is responsible for the cost difference between the non-preferred brand name drug and its generic equivalent (ancillary charge), plus the copayment for the non-non- preferred brand name drug. • The copayment for up to a 30 day supply at either the retail or mail service pharmacy, will be $5 for generic/Level One drugs $25, for preferred brand/Level Two drugs and $45 for non-preferred brand/Level Three drugs. Effective January 1, 2022, t The copayment for up to a 30-day supply at either the retail, specialty or mail service pharmacy will be $5 for generic/Level One drugs, $30 for preferred brand/Level Two drugs and $60 for non-preferred brand/Level Three drugs. • The copayment for a 31 to 90 day supply at the retail pharmacy will be $10 for generic/Level One drugs, $50 for preferred brand/Level Two drugs and $90 for non- preferred brand/Level Three drugs. Effective January 1, 2022, t The copayment for a 31 to 90 day supply at the retail or specialty pharmacy will be $10 for generic/Level One drugs, $60 for preferred brand/Level Two drugs and $120 for non- non-preferred brand/Level Three drugs. • The copayment for a 31 to 90 day supply at the mail service pharmacy will be $5 for ge- nericgeneric/Level One drugs, $50 for preferred brand/Level Two drugs and $90 for non- preferred brand/Level Three drugs. Effective January 1, 2022, t The copayment for a 31 to 90 day supply at the mail service pharmacy will be $5 for generic/Level One drugs, $55 for preferred brand/Level Two drugs and $110 for non-pre- ferred preferred brand/Level Three drugs. • Prescription drugs will be dispensed through either the preferred provider community pharmacy network (retail pharmacy), or the mail service pharmacy. • Coverage will be provided under the Empire Plan Prescription Drug Program for pre- scription prescription vitamins, contraceptive drugs, and contraceptive devices purchased at a phar- macypharmacy. * A medical exception program is available for non-formulary prescription drugs that are excluded from coverage. If a physician’s request for a medical exception is approved, the Level One copayment will apply for generic drugs and the Level Three copayment will apply for brand-name drugs. * A Dispense as Written exception request is available for medically necessary prescription non-preferred brand-name drugs that have a generic equivalent. If a physician’s request for medical necessity is approved, the Level Three copayment is charged, but the member will not be responsible for the difference in cost between the generic drug and the non-non- preferred brand-name drug (ancillary charge). * Annual changes may be made to the Advanced Flexible Formulary once a year on January 1st. Such changes may include moving drugs to a higher or lower level, and coverage of previously excluded drugs. Access to one or more drugs in select therapeutic categories may be excluded if the drugs have no clinical advantage over other generic or brand names drugs in the same therapeutic class. Drugs considered to have no clinical advantage that may be excluded include any products that: