Common use of pharmacotherapy Clause in Contracts

pharmacotherapy. Medical services are provided by licensed Health Care Professionals with specific training in managing your Smoking Cessation Program. described as follows: The program is o Individual counseling at an In-network Practitioner’s/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner or the In-network specialist Copayment applies. o Group counseling, including classes or a telephone Quit Line, are Covered through an In-network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. o Some organizations, such as the American Cancer Society and Tobacco Use Call PC 505‐923‐5678 1‐800‐356‐2219 Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. SC For more information contact our Presbyterian Customer Service Center at (505) 923- 5678 or toll-free at 0-000-000-0000, Monday through Friday from 7:00 a.m. to 6:00 p.m. Hearing impaired users may call our TTY line at (000) 000-0000 or toll-free at 1-877- 298-7407. Pharmacotherapy benefit Limitations o Prescription Drugs/Medications purchased at an In-network Pharmacy o Two 90-day courses of treatment per Calendar Year R fer to Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. ⮚ Transplants Exclusion This benefit has one or more exclusions as specified in the Exclusions section. • All Organ t ansplants Authorization. must be performed at an approved center and require Prior Prior Auth • Human Solid Organ transplant benefits are Covered for: Required o Kidney o liver o pancreas o intestine o heart o lung o multi-visceral (3 or more abdominal Organs) o simultaneous multi-Organ transplants – unless investigational o pancreas islet cell infusion. • Meniscal Allograft • Autologous Chondrocyte Implantation – knee only • Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple myeloma o leukemia o aplastic anemia o lymphoma o severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ cell tumor o neuroblastoma o Wilm’s Tumor o myelodysplastic Syndrome o myelofibrosis o sickle cell disease o thalassemia major

pharmacotherapy. Medical services are provided by licensed Health Care Professionals with specific training in managing your Smoking Cessation Program. described as follows: The program is o Individual counseling at an In-network Practitioner’sa Practitioner/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner non-specialist or the In-network specialist Copayment applies. o Group counseling, including classes or a telephone Quit Line, Line are Covered through an In-network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. o Some organizations, such as the American Cancer Society and Tobacco Use Call PC 505‐923‐5678 1‐800‐356‐2219 Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. group counseling services at no charge. SC Call PC 505‐923‐6980 1‐800‐923‐6980 For more information contact our Presbyterian Customer Service Center at (505) 923- 5678 6980 or toll-free at 0-000-000-0000, Monday through Friday from 7:00 a.m. to 6:00 p.m. Hearing impaired users may call our TTY line at (000) 000-0000 711 or toll-free at 1-877- 298800-7407659- 8331. Pharmacotherapy benefit Limitations o Prescription Drugs/Medications purchased at an In-network Pharmacy a Pharmacy. o Two 90-day courses of treatment per Calendar Year R fer Contract Year. Refer to Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. ⮚  Transplants Exclusion Prior Auth Required This benefit has one or more exclusions as specified in the Exclusions section. •  All Organ t ansplants Authorization. transplants must be performed at an approved center and require Prior Prior Auth • Authorization.  Human Solid Organ transplant benefits are Covered for: Required o Kidney kidney o liver o pancreas o intestine o heart o lung o multi-visceral (3 or more abdominal Organs) ). o simultaneous multi-Organ transplants – unless investigational o pancreas islet cell infusion. •  Meniscal Allograft •  Autologous Chondrocyte Implantation – knee only •  Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple myeloma o leukemia o aplastic anemia o lymphoma o severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ cell tumor o neuroblastoma o Wilm’s Tumor o myelodysplastic Syndrome o myelofibrosis o sickle cell disease o thalassemia majormajor Important 

pharmacotherapy. Medical services are provided by licensed Health Care Professionals with specific training in managing your Smoking Cessation Program. described as follows: The program is o Individual counseling at an In-network Practitioner’s/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner or the In-network specialist Copayment applies. o Group counseling, including classes or a telephone Quit Line, are Covered through an In-network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. o Some organizations, such as the American Cancer Society and Tobacco Use Call PC 505‐923‐5678 1‐800‐356‐2219 Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. SC For more information contact our Presbyterian Customer Service Center at (505) 923- 5678 or toll-free at 0-000-000-0000, Monday through Friday from 7:00 a.m. to 6:00 p.m. Hearing impaired users may call our TTY line at (000) 000-0000 or toll-free at 1-877- 298-7407. Pharmacotherapy benefit Limitations o Prescription Drugs/Medications purchased at an In-network Pharmacy o Two 90-day courses of treatment per Calendar Year R fer to Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. ⮚  Transplants Exclusion This benefit has one or more exclusions as specified in the Exclusions section. •  All Organ t ansplants Authorization. must be performed at an approved center and require Prior Prior Auth •  Human Solid Organ transplant benefits are Covered for: Required o Kidney o liver o pancreas o intestine o heart o lung o multi-visceral (3 or more abdominal Organs) o simultaneous multi-Organ transplants – unless investigational o pancreas islet cell infusion. •  Meniscal Allograft •  Autologous Chondrocyte Implantation – knee only •  Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple myeloma o leukemia o aplastic anemia o lymphoma o severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ cell tumor o neuroblastoma o Wilm’s Tumor o myelodysplastic Syndrome o myelofibrosis o sickle cell disease o thalassemia major

pharmacotherapy. Medical services are provided by licensed Health Care Professionals with specific training in managing your Smoking Cessation Program. The program is described as follows: The program is o Individual counseling at an In-network Practitioner’s/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner or the In-network specialist Copayment applies. o Group Grou counseling, including classes or a telephone Quit Line, are Covered through an In-network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. o Some organizations, such as the American Cancer Society and Tobacco Use Call PC 505‐923‐5678 1‐800‐356‐2219 Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. SC group counseling services at no charge. CSC Call P 505‐923‐5678 1‐800‐356‐2219 For more information contact our Presbyterian Customer Service Center at (505) 923- 5678 678 or toll-free at 0-000-000-0000, Monday through Friday from 7:00 a.m. to 6:00 p.m. p 8 .m. Hearing impaired users may call our TTY line at (000) 000-0000 711 or toll-free at 1-877- 298800-7407659- 331. Pharmacotherapy benefit Limitations o Prescription Drugs/Medications purchased at an In-network Pharmacy o Two 90-day courses of treatment per Calendar Contract Year R fer to Exclusion Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. ⮚ Refer to  Transplants Exclusion This benefit has one or more exclusions as specified in the Exclusions section. •  All Organ t ansplants transplants must be Prior Auth Required Authorization. must be performed at an approved center and require Prior Prior Auth •  Human Solid Organ transplant benefits are Covered for: Required o Kidney kidney o liver o pancreas o intestine o heart o lung o multi-visceral (3 or more abdominal Organs) o simultaneous multi-Organ transplants – unless investigational o pancreas islet cell infusion. • infusion  Meniscal Allograft •  Autologous Chondrocyte Implantation – knee only •  Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants t ansplants are Covered for the following indications: Bone o multiple myeloma o leukemia o aplastic anemia o lymphoma lymp oma o severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ cell tumor o neuroblastoma o Wilm’s Tumor o myelodysplastic Syndrome o myelofibrosis o sickle cell disease o thalassemia major