Common use of HSA Preventive Drug List Clause in Contracts

HSA Preventive Drug List. This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. Summary of Pharmacy Benefits Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 - After deductible Not Covered Tier 2: $45 - After deductible Not Covered Tier 3: $70 - After deductible Not Covered Tier 4: $90 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and non- maintenance prescription drugs. Tier 1: $25 - After deductible Not Covered Tier 2: $112.50 - After deductible Not Covered Tier 3: $175 - After deductible Not Covered Tier 4: $270 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered

HSA Preventive Drug List. This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. Summary of Pharmacy Benefits Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which includes Glucometers, Test Strips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, calibration fluid): When purchased at a Retail Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 0 - After deductible Not Covered Tier 2: $45 0 - After deductible Not Covered Tier 3: $70 0 - After deductible Not Covered Tier 4: $90 0 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and non- maintenance prescription drugs. Tier 1: $25 0 - After deductible Not Covered Tier 2: $112.50 0 - After deductible Not Covered Tier 3: $175 0 - After deductible Not Covered Tier 4: $270 0 - After deductible Not Covered Tier 5: See specialty prescription drug section below. Not Covered HSA Preventive Prescription Drugs - Coverage for certain preventive prescription drugs before meeting your plan year deductible. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. When purchased at a Retail or Specialty Pharmacy: For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for a shorter supply periodmay apply for network pharmacy only. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain retail pharmacies. For a 90-day supply; three retail copayments apply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 $0 - After deductible Not Covered Tier 2: $50 $0 - After deductible Not Covered Tier 3: $75 $0 - After deductible Not Covered Tier 4: $95 $0 - After deductible Not Covered Tier 5: Not applicable before deductible. See specialty prescription drug section below for after deductible. Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+) Preauthorization is required for thisservice. Please see Preauthorization in Section 3 for more information. You Pay You Pay When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and non- maintenance prescription drugs. Tier 1: $25 $0 - After deductible Not Covered Tier 2: $125 $0 - After deductible Not Covered Tier 3: $187.50 $0 - After deductible Not Covered Tier 4: $285 $0 - After deductible Not Covered Tier 5: Not Applicable Not Covered

HSA Preventive Drug List. This plan allows for certain preventive prescriptions drugs to be covered, with a copayment, before meeting your plan year deductible. See the Summary of Pharmacy Benefits for the applicable copayment. For a list of these preventive prescription drugs, please visit our website or call our Customer Service Department. SG-COC-2-2019-BX & SG-SOB-17b-2019-BX 7 BlueSolutions for HSA Summary of Pharmacy Benefits Covered Benefits Network Pharmacy Non-network Pharmacy (+) )Preauthorization is required for thisservicethis service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Prescription Drugs, other than Specialty Prescription Drugs, and Diabetic Equipment and Supplies (which Suppliesw( hich includes Glucometers, Test StripsTtesStrips, Lancet and Lancet Devices, Needles and Syringes, and Miscellaneous Supplies, Suppl calibration fluid): When purchased at a Retail Pharmacy: For Copaymentapplies per each 3-0day supply or portion thereof for maintenance and nonn-maintenance omnaintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribeddosing period. Prorated copayments for Proratedcopaymentsfor a shorter supply periodmay period may apply for network pharmacy onlyfornetwork pharmacoynly. See Prescription Drug section for details. For tiers 1, 2, and 3: Up to a 90-day supply of maintenance and non-maintenance prescription drugs is available at certain network retail pharmacies and a 365-day supply for contraceptive prescription drugs is available at all network pharmacies. A copayment will apply for each 30-day supply. For more information about pharmacies offering this option, visit our website. Tier 1: $10 - After deductible 10- Afterdeductible Not Covered Tier 2: $45 - After deductible 30- Afterdeductible Not Covered Tier 3: $70 - After deductible 50- Afterdeductible Not Covered Tier 4: $90 - After deductible 75- Afterdeductible Not Covered Tier 5: See specialty Seespecialty prescription drug section drusgection below. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and non- n-on maintenance prescription drugs. Tier 1: $25 - After deductible 25- Afterdeductible Not Covered Tier 2: $112.50 - After deductible 75- Afterdeductible Not Covered Tier 3: $175 - After deductible 125- Afterdeductible Not Covered Tier 4: $270 - After deductible 225- Afterdeductible Not Covered Tier 5: See specialty Seespecialty prescription drug section drusgection below. Not Covered Specialty Prescription Drugs (+)Prorated copayments for a shorter supply period may apply nfoetrwork pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy(+): Tier 5: $125- Afterdeductible Not Covered Copaymentapplies per each 3-0day supply or applies per recommended treatment interval. When purchased at a Retail Pharmacy(+): Tier 5: 50%- Afterdeductible Not Covered Copaymentapplies per each 3-0day supply or applies per recommended treatment intervSapl.ecialty Prescription Drugpsurchased at a ertailpharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. When purchased at a Mail Order Pharmacy: Not Covered Not Covered Infertility Prescription Drugs- Three (3) i-nvitro cycles will be covered perplan yearwith a total of eight (8)-viintro cycles covered in a P H liPfetimE e. H U ¶ V When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20%- Afterdeductible Not Covered Tier 2: 20%- Afterdeductible Not Covered Tier 3: 20%- Afterdeductible Not Covered Tier 4: 20%- Afterdeductible Not Covered When purchased at a Specialty Pharmacy(+) Tier 5: 20%- Afterdeductible Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy w require a significantly higher out of poecxkpeet nse than if purchased from a specialty pharmacy. Tier 5: 20%- Afterdeductible Not Covered Covered Benefits Network Pharmacy Non-network Pharmacy (+)Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Contraceptive Methods - Coverage includes barrier method (diaphragm or cervical cap), hormonal method (b control pill), and emergency contraception. When purchased at a Retail Pharmacy: Copaymentapplies per each 3-0day supply or portion thereof of maintenance and n-omnaintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $30- Afterdeductible Not Covered Tier 3: $50- Afterdeductible Not Covered Tier 4: $75- Afterdeductible Not Covered Tier 5: Contraceptives are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply of maintenance and n-on maintenance prescription drugs. Tier 1: $0 Not Covered Tier 2: $75- Afterdeductible Not Covered Tier 3: $125- Afterdeductible Not Covered Tier 4: $225- Afterdeductible Not Covered Tier 5:Contraceptives are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered