Common use of Participating Pharmacies Clause in Contracts

Participating Pharmacies. The PBM’s Participating Pharmacies are available to Enrollees who use medically necessary drugs Participating mail service pharmacies have toll free access to registered pharmacists to answer your questions. Participating specialty pharmacies have dedicated patient care coordinators to help You manage Your condition and offer toll-free twenty-four hour access to nurses and registered Pharmacists. You may obtain a list of the Participating Pharmacies, and Covered Drugs, by calling the Customer Service telephone number on the back of Your ID card, or review the lists on Our website at xxx.xxxxxxxxxxxxxxxxx.xxx. Covered Prescription Drug Benefits include the following.  Prescription Legend 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.  If certain supplies, equipment or appliances are not obtained by Mail Service or from a Participating Pharmacy then they are Covered as Medical Supplies, Equipment and Appliances instead of under Prescription Drug benefits and may be subject to applicable DME Copays or Coinsurance.  Injectables.  Medical food that is Medically Necessary and prescribed by a Physician for the treatment of an inherited metabolic disease. Medical food means a formula that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and formulated to be consumed or administered enterally under the direction of a Physician. Non-Covered Prescription Drug Benefits  Prescription Drugs dispensed by any Mail Service program other than the PBM’s Mail Service, unless prohibited by law.  Drugs, devices and products, or Prescription Legend Drugs with over the counter equivalents and any Drugs, devices or products that are therapeutically comparable to an over the counter Drug, device, or product.  Off label use, except as otherwise prohibited by law or as approved by Us or the PBM.  Drugs in quantities exceeding the quantity prescribed, or for any refill dispensed later than one year after the date of the original Prescription Order.  Drugs not approved by the FDA.  Charges for the administration of any Drug.  Drugs consumed at the time and place where dispensed or where the Prescription Order is issued, including but not limited to samples provided by a Physician. This does not apply to Drugs used in conjunction with a Diagnostic Service, with Chemotherapy performed in the office or Drugs eligible for Coverage under the Medical Supplies benefit, they are Covered Health Services.  Any Drug which is primarily for weight loss.  Drugs not requiring a prescription by federal law (including Drugs requiring a prescription by state law, but not by federal law), except for injectable insulin.  Any new FDA Approved Drug Product or Technology (including but not limited to medications, medical supplies, or devices) available in the marketplace for dispensing by the appropriate source for the product or technology, including but not limited to Pharmacies, for the first six months after the product or technology received FDA New Drug Approval or other applicable FDA approval. The Contract may at its sole discretion, waive this exclusion in whole or in part for a specific New FDA Approved Drug Product or Technology.Fertility Drugs.  Contraceptive devices, oral immunizations, and biologicals, although they are federal legend Drugs, are payable as medical supplies based on where the service is performed or the item is obtained. If such items are over the counter Drugs, devices or products, they are not Covered Health Services.  Compound Drugs unless there is at least one ingredient that requires a prescription.  Treatment of Onchomycosis (toenail fungus).  Refills of lost or stolen medications.  Refills earlier than 72 hours before Your next refill is due.  Refills on expired Prescription Drugs.  Certain brand name Prescription Drugs, for which there are lower cost clinically equivalent alternatives available, are not Covered, unless otherwise required by law or approved by Us. “Clinically equivalent” means Drugs that, for the majority of Enrollees, can be expected to produce similar therapeutic outcomes for a disease or condition.  Tier 1Drugs have the lowest Copay. This class will contain low cost and preferred medications that may be Generic, single source Brand Drugs, or multi-source Brand Drugs.  Tier 2 Drugs will have a higher Copay than Tier 1 Prescription Drugs. This class will contain preferred medications that may be Generic, single source, or multi-source Brand Drugs.  Tier 3Prescription Drugs will have a required Coinsurance payment after You have hit your Deductible. This class will contain non-preferred and high cost medications. This will include medications considered Generic, single source brands, and multi-source brands.  Tier 4 Prescriptions are subject to a day supply limit for Retail and Mail Service, and are subject to the applicable Coinsurance shown in the Schedule of Benefits. Coinsurance payment will occur after You have hit your Deductible. Tier 4 Drugs are Prescription Legend Drugs which are any of the following listed below. o Are only approved to treat limited patient populations, indications or conditions, or o Are normally injected, infused or require close monitoring by a physician or clinically trained individual, or o Have limited availability, special dispensing and delivery requirements, and/or require additional patient support – any or all of which make the Drug difficult to obtain through traditional pharmacies. The determinations of Prescription Drug class assignments and formulary inclusion are made by Us based upon clinical decisions provided by the National P&T Committee, and where appropriate, the cost of the Drug relative to other Drugs in its therapeutic class or used to treat the same or similar condition, the availability of over-the-counter alternatives, generic availability, the degree of utilization of one Drug over another in Our patient population, and where appropriate, certain clinical economic factors. We retain the right at Our discretion to determine Coverage for dosage formulations in terms of Covered dosage administration methods (for example, by mouth, injections, topical, or inhaled) and may Cover one form of administration and exclusion or place other forms of administration in another tier.

Participating Pharmacies. The PBM’s Participating Pharmacies are available to Enrollees who use medically necessary drugs Participating mail service pharmacies have toll free access to registered pharmacists to answer your questions. Participating specialty pharmacies have dedicated patient care coordinators to help You manage Your condition and offer toll-free twenty-four hour access to nurses and registered Pharmacists. You may obtain a list of the Participating Pharmacies, and Covered Drugs, by calling the Customer Service telephone number on the back of Your ID card, or review the lists on Our website at xxx.xxxxxxxxxxxxxxxxx.xxx. Covered Prescription Drug Benefits include the following.  Prescription Legend 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.  If certain supplies, equipment or appliances are not obtained by Mail Service or from a Participating Pharmacy then they are Covered as Medical Supplies, Equipment and Appliances instead of under Prescription Drug benefits and may be subject to applicable DME Copays or Coinsurance.  Injectables.  Medical food that is Medically Necessary and prescribed by a Physician for the treatment of an inherited metabolic disease. Medical food means a formula that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and formulated to be consumed or administered enterally under the direction of a Physician. Non-Covered Prescription Drug Benefits  Prescription Drugs dispensed by any Mail Service program other than the PBM’s Mail Service, unless prohibited by law.  Drugs, devices and products, or Prescription Legend Drugs with over the counter equivalents and any Drugs, devices or products that are therapeutically comparable to an over the counter Drug, device, or product.  Off label use, except as otherwise prohibited by law or as approved by Us or the PBM.  Drugs in quantities exceeding the quantity prescribed, or for any refill dispensed later than one year after the date of the original Prescription Order.  Drugs not approved by the FDA.  Charges for the administration of any Drug.  Drugs consumed at the time and place where dispensed or where the Prescription Order is issued, including but not limited to samples provided by a Physician. This does not apply to Drugs used in conjunction with a Diagnostic Service, with Chemotherapy performed in the office or Drugs eligible for Coverage under the Medical Supplies benefit, they are Covered Health Services.  Any Drug which is primarily for weight loss.  Drugs not requiring a prescription by federal law (including Drugs requiring a prescription by state law, but not by federal law), except for injectable insulin.  Any new FDA Approved Drug Product or Technology (including but not limited to medications, medical supplies, or devices) available in the marketplace for dispensing by the appropriate source for the product or technology, including but not limited to Pharmacies, for the first six months after the product or technology received FDA New Drug Approval or other applicable FDA approval. The Contract may at its sole discretion, waive this exclusion in whole or in part for a specific New FDA Approved Drug Product or Technology..  Fertility Drugs.  Contraceptive devices, oral immunizations, and biologicals, although they are federal legend Drugs, are payable as medical supplies based on where the service is performed or the item is obtained. If such items are over the counter Drugs, devices or products, they are not Covered Health Services.  Compound Drugs unless there is at least one ingredient that requires a prescription.  Treatment of Onchomycosis (toenail fungus).  Refills of lost or stolen medications.  Refills earlier than 72 hours before Your next refill is due.  Refills on expired Prescription Drugs.  Certain brand name Prescription Drugs, for which there are lower cost clinically equivalent alternatives available, are not Covered, unless otherwise required by law or approved by Us. “Clinically equivalent” means Drugs that, for the majority of Enrollees, can be expected to produce similar therapeutic outcomes for a disease or condition.  Tier 1Drugs have the lowest Copay. This class will contain low cost and preferred medications that may be Generic, single source Brand Drugs, or multi-source Brand Drugs.  Tier 2 Drugs will have a higher Copay than Tier 1 Prescription Drugs. This class will contain preferred medications that may be Generic, single source, or multi-source Brand Drugs.  Tier 3Prescription Drugs will have a required Coinsurance payment after You have hit your Deductible. This class will contain non-preferred and high cost medications. This will include medications considered Generic, single source brands, and multi-source brands.  Tier 4 Prescriptions are subject to a day supply limit for Retail and Mail Service, and are subject to the applicable Coinsurance shown in the Schedule of Benefits. Coinsurance payment will occur after You have hit your Deductible. Tier 4 Drugs are Prescription Legend Drugs which are any of the following listed below. o Are only approved to treat limited patient populations, indications or conditions, or o Are normally injected, infused or require close monitoring by a physician or clinically trained individual, or o Have limited availability, special dispensing and delivery requirements, and/or require additional patient support – any or all of which make the Drug difficult to obtain through traditional pharmacies. The determinations of Prescription Drug class assignments and formulary inclusion are made by Us based upon clinical decisions provided by the National P&T Committee, and where appropriate, the cost of the Drug relative to other Drugs in its therapeutic class or used to treat the same or similar condition, the availability of over-the-counter alternatives, generic availability, the degree of utilization of one Drug over another in Our patient population, and where appropriate, certain clinical economic factors. We retain the right at Our discretion to determine Coverage for dosage formulations in terms of Covered dosage administration methods (for example, by mouth, injections, topical, or inhaled) and may Cover one form of administration and exclusion or place other forms of administration in another tier.

Participating Pharmacies. The PBM’s Participating Pharmacies are available to Enrollees who use medically necessary drugs Participating mail service pharmacies have toll free access to registered pharmacists to answer your questions. Participating specialty pharmacies have dedicated patient care coordinators to help You manage Your condition and offer toll-free twenty-four hour access to nurses and registered Pharmacists. You may obtain a list of the Participating Pharmacies, and Covered Drugs, by calling the Customer Service telephone number on the back of Your ID card, or review the lists on Our website at xxx.xxxxxxxxxxxxxxxxx.xxx. Covered Prescription Drug Benefits include the following.  Prescription Legend 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.  If certain supplies, equipment or appliances are not obtained by Mail Service or from a Participating Pharmacy then they are Covered as Medical Supplies, Equipment and Appliances instead of under Prescription Drug benefits and may be subject to applicable DME Copays or Coinsurance.  Injectables.  Medical food that is Medically Necessary and prescribed by a Physician for the treatment of an inherited metabolic disease. Medical food means a formula that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and formulated to be consumed or administered enterally under the direction of a Physician. Non-Covered Prescription Drug Benefits  Prescription Drugs dispensed by any Mail Service program other than the PBM’s Mail Service, unless prohibited by law.  Drugs, devices and products, or Prescription Legend Drugs with over the counter equivalents and any Drugs, devices or products that are therapeutically comparable to an over the counter Drug, device, or product.  Off label use, except as otherwise prohibited by law or as approved by Us or the PBM.  Drugs in quantities exceeding the quantity prescribed, or for any refill dispensed later than one year after the date of the original Prescription Order.  Drugs not approved by the FDA.  Charges for the administration of any Drug.  Drugs consumed at the time and place where dispensed or where the Prescription Order is issued, including but not limited to samples provided by a Physician. This does not apply to Drugs used in conjunction with a Diagnostic Service, with Chemotherapy performed in the office or Drugs eligible for Coverage under the Medical Supplies benefit, they are Covered Health Services.  Any Drug which is primarily for weight loss.  Drugs not requiring a prescription by federal law (including Drugs requiring a prescription by state law, but not by federal law), except for injectable insulin.  Any new FDA Approved Drug Product or Technology (including but not limited to medications, medical supplies, or devices) available in the marketplace for dispensing by the appropriate source for the product or technology, including but not limited to Pharmacies, for the first six months after the product or technology received FDA New Drug Approval or other applicable FDA approval. The Contract may at its sole discretion, waive this exclusion in whole or in part for a specific New FDA Approved Drug Product or Technology..  Fertility Drugs.  Contraceptive devices, oral immunizations, and biologicals, although they are federal legend Drugs, are payable as medical supplies based on where the service is performed or the item is obtained. If such items are over the counter Drugs, devices or products, they are not Covered Health Services.  Human Growth Hormone for children born small for gestational age. It is only a Covered Service in other situations when allowed by Us through Prior Authorization.  Compound Drugs unless there is at least one ingredient that requires a prescription.  Treatment of Onchomycosis (toenail fungus).  Refills of lost or stolen medications.  Refills earlier than 72 hours before Your next refill is due.  Refills on expired Prescription Drugs.  Certain brand name Prescription Drugs, for which there are lower cost clinically equivalent alternatives available, are not Covered, unless otherwise required by law or approved by Us. “Clinically equivalent” means Drugs that, for the majority of Enrollees, can be expected to produce similar therapeutic outcomes for a disease or condition. PBM and request an override for one additional refill. This will allow You to fill Your next prescription early. If You require more than one extra refill, please call the Pharmacy Customer Service telephone number on the back of Your I.D. Card.  Tier 1Drugs have the lowest Copay. This class will contain low cost and preferred medications that may be Generic, single source Brand Drugs, or multi-source Brand Drugs.  Tier 2 Drugs will have a higher Copay than Tier 1 Prescription Drugs. This class will contain preferred medications that may be Generic, single source, or multi-source Brand Drugs.  Tier 3Prescription Drugs will have a required Coinsurance payment after You have hit your Deductible. This class will contain non-preferred and high cost medications. This will include medications considered Generic, single source brands, and multi-source brands.  Tier 4 Prescriptions are subject to a day supply limit for Retail and Mail Service, and are subject to the applicable Coinsurance shown in the Schedule of Benefits. Coinsurance payment will occur after You have hit your Deductible. Tier 4 Drugs are Prescription Legend Drugs which are any of the following listed below. o Are only approved to treat limited patient populations, indications or conditions, or o Are normally injected, infused or require close monitoring by a physician or clinically trained individual, or o Have limited availability, special dispensing and delivery requirements, and/or require additional patient support – any or all of which make the Drug difficult to obtain through traditional pharmacies. The determinations of Prescription Drug class assignments and formulary inclusion are made by Us based upon clinical decisions provided by the National P&T Committee, and where appropriate, the cost of the Drug relative to other Drugs in its therapeutic class or used to treat the same or similar condition, the availability of over-the-counter alternatives, generic availability, the degree of utilization of one Drug over another in Our patient population, and where appropriate, certain clinical economic factors. We retain the right at Our discretion to determine Coverage for dosage formulations in terms of Covered dosage administration methods (for example, by mouth, injections, topical, or inhaled) and may Cover one form of administration and exclusion or place other forms of administration in another tier.

Participating Pharmacies. The PBM’s Participating Pharmacies are available to Enrollees who use medically necessary drugs Participating mail service pharmacies have toll free access to registered pharmacists to answer your questions. Participating specialty pharmacies have dedicated patient care coordinators to help You manage Your condition and offer toll-free twenty-four hour access to nurses and registered Pharmacists. You may obtain a list of the Participating Pharmacies, and Covered Drugs, by calling the Customer Service telephone number on the back of Your ID card, or review the lists on Our website at xxx.xxxxxxxxxxxxxxxxx.xxx. Covered Prescription Drug Benefits include the following.  Prescription Legend 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.  If certain supplies, equipment or appliances are not obtained by Mail Service or from a Participating Pharmacy then they are Covered as Medical Supplies, Equipment and Appliances instead of under Prescription Drug benefits and may be subject to applicable DME Copays or Coinsurance.  Injectables.  Medical food that is Medically Necessary and prescribed by a Physician for the treatment of an inherited metabolic disease. Medical food means a formula that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and formulated to be consumed or administered enterally under the direction of a Physician. Non-Covered Prescription Drug Benefits  Prescription Drugs dispensed by any Mail Service program other than the PBM’s Mail Service, unless prohibited by law.  Drugs, devices and products, or Prescription Legend Drugs with over the counter equivalents and any Drugs, devices or products that are therapeutically comparable to an over the counter Drug, device, or product.  Off label use, except as otherwise prohibited by law or as approved by Us or the PBM.  Drugs in quantities exceeding the quantity prescribed, or for any refill dispensed later than one year after the date of the original Prescription Order.  Drugs not approved by the FDA.  Charges for the administration of any Drug.  Drugs consumed at the time and place where dispensed or where the Prescription Order is issued, including but not limited to samples provided by a Physician. This does not apply to Drugs used in conjunction with a Diagnostic Service, with Chemotherapy performed in the office or Drugs eligible for Coverage under the Medical Supplies benefit, they are Covered Health Services.  Any Drug which is primarily for weight loss.  Drugs not requiring a prescription by federal law (including Drugs requiring a prescription by state law, but not by federal law), except for injectable insulin.  Any new FDA Approved Drug Product or Technology (including but not limited to medications, medical supplies, or devices) available in the marketplace for dispensing by the appropriate source for the product or technology, including but not limited to Pharmacies, for the first six months after the product or technology received FDA New Drug Approval or other applicable FDA approval. The Contract may at its sole discretion, waive this exclusion in whole or in part for a specific New FDA Approved Drug Product or Technology.Fertility Drugs.  Contraceptive devices, oral immunizations, and biologicals, although they are federal legend Drugs, are payable as medical supplies based on where the service is performed or the item is obtained. If such items are over the counter Drugs, devices or products, they are not Covered Health Services.  Compound Drugs unless there is at least one ingredient that requires a prescription.  Treatment of Onchomycosis (toenail fungus).  Refills of lost or stolen medications.  Refills earlier than 72 hours before Your next refill is due.  Refills on expired Prescription Drugs.  Certain brand name Prescription Drugs, for which there are lower cost clinically equivalent alternatives available, are not Covered, unless otherwise required by law or approved by Us. “Clinically equivalent” means Drugs that, for the majority of Enrollees, can be expected to produce similar therapeutic outcomes for a disease or condition.  Tier 1Drugs have the lowest Copay. This class will contain low cost and preferred medications that may be Generic, single source Brand Drugs, or multi-source Brand Drugs.  Tier 2 Drugs will have a higher Copay than Tier 1 Prescription Drugs. This class will contain preferred medications that may be Generic, single source, or multi-source Brand Drugs.  Tier 3Prescription Drugs will have a required Coinsurance payment after You have hit your Deductible. This class will contain non-preferred and high cost medications. This will include medications considered Generic, single source brands, and multi-source brands.  Tier 4 Prescriptions are subject to a day supply limit for Retail and Mail Service, and are subject to the applicable Coinsurance shown in the Schedule of Benefits. Coinsurance payment will occur after You have hit your Deductible. Tier 4 Drugs are Prescription Legend Drugs which are any of the following listed below. o Are only approved to treat limited patient populations, indications or conditions, or o Are normally injected, infused or require close monitoring by a physician or clinically trained individual, or o Have limited availability, special dispensing and delivery requirements, and/or require additional patient support – any or all of which make the Drug difficult to obtain through traditional pharmacies. The determinations of Prescription Drug class assignments and formulary inclusion are made by Us based upon clinical decisions provided by the National P&T Committee, and where appropriate, the cost of the Drug relative to other Drugs in its therapeutic class or used to treat the same or similar condition, the availability of over-the-counter alternatives, generic availability, the degree of utilization of one Drug over another in Our patient population, and where appropriate, certain clinical economic factors. We retain the right at Our discretion to determine Coverage for dosage formulations in terms of Covered dosage administration methods (for example, by mouth, injections, topical, or inhaled) and may Cover one form of administration and exclusion or place other forms of administration in another tier.