Common use of Medications Benefits Clause in Contracts

Medications Benefits. Injectable medications, except Self-injectable Drugs eligible for coverage under the Prescription Drug Rider, are a Covered Benefit when an oral alternative drug is not available, unless specifically excluded as described in the Exclusions and Limitations section of this Certificate. Medications must be prescribed by a Provider licensed to prescribe federal legend prescription drugs or medicines, and pre-authorized by HMO. If the drug therapy treatment is approved for self-administration, the Member is required to obtain covered medications at an HMO Participating pharmacy designated to fill injectable prescriptions. Injectable drugs or medication used for the treatment of cancer or Human Immunodeficiency Virus (HIV) are covered when the off-label use of the drug has not been approved by the Food and Drug Administration (FDA) for that indication, provided that such drug is recognized for treatment of such indication in one of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) and the safety and effectiveness of use for this indication has been adequately demonstrated by at least one study published in a nationally recognized peer reviewed journal. HMO NC COC AMENDSI (03-04) AETNA HEALTH INC. (NORTH CAROLINA) HOME HEALTH CARE AMENDMENT Contract Holder Group Agreement Effective Date: January 1, 2013 The Aetna Health Inc. Certificate is hereby amended as follows:

Medications Benefits. Injectable medications, except Self-injectable Drugs eligible for coverage under the Prescription Drug Rider, are a Covered Benefit when an oral alternative drug is not available, unless specifically excluded as described in the Exclusions and Limitations section of this Certificate. Medications must be prescribed by a Provider licensed to prescribe federal legend prescription drugs or medicines, and pre-authorized by HMO. If the drug therapy treatment is approved for self-administration, the Member is required to obtain covered medications at an HMO Participating pharmacy designated to fill injectable prescriptions. Injectable drugs or medication used for the treatment of cancer or Human Immunodeficiency Virus (HIV) HIV are covered when the off-label use of the drug has not been approved by the Food and Drug Administration (FDA) FDA for that indication, provided that such drug is recognized for treatment of such indication in one 1 of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) and the safety and effectiveness of use for this indication has been adequately demonstrated by at least one 1 study published in a nationally recognized peer reviewed journal. HMO NC COC GEN AMENDSI (03-04) 1 AETNA HEALTH INC. (NORTH CAROLINAKENTUCKY) HOME HEALTH CARE SUBROGATION AND WORKERS' COMPENSATION AMENDMENT Contract Holder Group Agreement Effective Date: January 1, 2013 The Aetna Health Inc. Certificate is hereby amended as follows: The Subrogation and Right of Recovery provision in the Certificate is hereby deleted and replaced with the following:

Medications Benefits. Injectable medications, except Self-injectable Drugs eligible for coverage under the Prescription Drug Rider, are a Covered Benefit when an oral alternative drug is not available, unless specifically excluded as described in the Exclusions and Limitations section of this Certificate. Medications must be prescribed by a Provider licensed to prescribe federal legend prescription drugs or medicines, and pre-authorized by HMO. If the drug therapy treatment is approved for self-administration, the Member is required to obtain covered medications at an HMO Participating pharmacy designated to fill injectable prescriptions. Injectable drugs or medication used for the treatment of cancer or Human Immunodeficiency Virus (HIV) HIV are covered when the off-label use of the drug has not been approved by the Food and Drug Administration (FDA) FDA for that indication, provided that such drug is recognized for treatment of such indication in one 1 of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) and the safety and effectiveness of use for this indication has been adequately demonstrated by at least one 1 study published in a nationally recognized peer reviewed journal. HMO NC COC ME AMENDSI (03-04) AETNA HEALTH INC. (NORTH CAROLINAMAINE) HOME HEALTH CARE METHOD OF PAYMENT AMENDMENT Contract Holder Group Agreement Effective Date: January 1, 2013 2009 The Aetna Health Inc. Certificate is hereby amended as follows: The Definitions Section of the Certificate is hereby amended such that the following definitions are added in their entirety as follows: The Method of Payment Section of the Certificate is deleted and replaced in its entirety as follows:

Medications Benefits. Injectable medications, except Self-injectable Drugs eligible for coverage under the Prescription Drug Rider, are a Covered Benefit when an oral alternative drug is not available, unless specifically excluded as described in the Exclusions and Limitations section of this Certificate. Medications must be prescribed by a Provider licensed to prescribe federal legend prescription drugs or medicines, and pre-authorized by HMO. If the drug therapy treatment is approved for self-administration, the Member is required to obtain covered medications at an HMO Participating pharmacy designated to fill injectable prescriptions. Injectable drugs or medication used for the treatment of cancer or Human Immunodeficiency Virus (HIV) HIV are covered when the off-label use of the drug has not been approved by the Food and Drug Administration (FDA) FDA for that indication, provided that such drug is recognized for treatment of such indication in one 1 of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) and the safety and effectiveness of use for this indication has been adequately demonstrated by at least one 1 study published in a nationally recognized peer reviewed journal. HMO NC COC ME AMENDSI (03-04) AETNA HEALTH INC. (NORTH CAROLINAMAINE) HOME HEALTH CARE METHOD OF PAYMENT AMENDMENT Contract Holder Group Agreement Effective Date: January 1, 2013 2010 The Aetna Health Inc. Certificate is hereby amended as follows: The Definitions Section of the Certificate is hereby amended such that the following definitions are added in their entirety as follows: The Method of Payment Section of the Certificate is deleted and replaced in its entirety as follows: