Common use of Prescription Drug Benefits Clause in Contracts

Prescription Drug Benefits. Benefits are available for outpatient prescription Drugs. Outpatient prescription Drugs are self-administered Drugs approved by the U.S. Food and Drug Administration (FDA) for sale to the public through retail or mail-order pharmacies that are prescribed and are not provided for use on an inpatient basis. Drugs also include diabetic testing supplies. A Physician or Health Care Provider must prescribe all Drugs covered under this Benefit, including over-the-counter items. You must obtain all Drugs from a Participating Pharmacy, except as noted below. Drugs, items, and services that are not covered under this Benefit are listed in the Exclusions and limitations section. Some Drugs, most Specialty Drugs, and prescriptions for Drugs exceeding specific quantity limits require prior authorization to be covered. The prior authorization process is described in the Prior authorization/exception request/step therapy process section. You or your Physician may request prior authorization from Blue Shield. Blue Shield’s Drug Formulary is a list of FDA-approved preferred Generic and Brand Drugs. This list helps Physicians or Health Care Providers prescribe Medically Necessary and cost-effective Drugs. Blue Shield’s Formulary is established and maintained by Blue Shield’s Pharmacy and Therapeutics (P&T) Committee. This committee consists of Physicians and pharmacists responsible for evaluating Drugs for relative safety, effectiveness, evidence-based health benefit, and comparative cost. The committee also reviews new Drugs, dosage forms, usage, and clinical data to update the Formulary four times a year. Your Physician or Health Care Provider might prescribe a Drug even though it is not included in the Blue Shield Formulary. The Formulary is divided into Drug tiers. The tiers are described in the chart below. Your Copayment or Coinsurance will vary based on the Drug tier. Drugs are placed into tiers based on recommendations made by the P&T Committee. Tier 1 • Most Generic Drugs or low-cost preferred Brand Drugs Tier 2 • Non-preferred Generic Drugs • Preferred Brand Drugs • Any other Drugs recommended by the P&T Committee based on drug safety, efficacy, and cost Tier 3 • Non-preferred Brand Drugs • Drugs recommended by the P&T Committee based on drug safety, efficacy, and cost • Drugs that generally have a preferred and often less costly therapeutic alternative at a lower tier Tier 4 • Drugs that are biologics, and Drugs the FDA or drug manufacturer requires to be distributed through Network Specialty Pharmacies • Drugs that require you to have special training or clinical monitoring • Drugs that cost the plan more than $600 (net of rebates) for a one-month supply Visit xxxxxxxxxxxx.xxx/xxxxxxxx, use the Blue Shield mobile app, or contact Customer Service for more information on the Drug Formulary or to request a printed copy of the Formulary.

Prescription Drug Benefits. Benefits are available for outpatient prescription Drugs. Outpatient prescription Drugs are self-administered Drugs approved by the U.S. Food and Drug Administration (FDA) for sale to the public through retail or mail-order pharmacies that are prescribed and are not provided for use on an inpatient basis. Drugs also include diabetic testing supplies. A Physician or Health Care Provider must prescribe all Drugs covered under this Benefit, including over-the-counter items. You must obtain all Drugs from a Participating Pharmacy, except as noted below. Drugs, items, and services that are not covered under this Benefit are listed in the Exclusions and limitations section. Some Drugs, most Specialty Drugs, and prescriptions for Drugs exceeding specific quantity limits require prior authorization to be covered. The prior authorization process is described in the Prior authorization/exception request/step therapy process section. You or your Physician may request prior authorization from Blue Shield. Blue Shield’s Drug Formulary is a list of FDA-approved preferred Generic and Brand Drugs. This list helps Physicians or Health Care Providers prescribe Medically Necessary and cost-effective Drugs. Blue Shield’s Formulary is established and maintained by Blue Shield’s Pharmacy and Therapeutics (P&T) Committee. This committee consists of Physicians and pharmacists responsible for evaluating Drugs for relative safety, effectiveness, evidence-based health benefit, and comparative cost. The committee also reviews new Drugs, dosage forms, usage, and clinical data to update the Formulary four times a year. Your Physician or Health Care Provider might prescribe a Drug even though it is not included in the Blue Shield Formulary. The Formulary is divided into Drug tiers. The tiers are described in the chart below. Your Copayment or Coinsurance will vary based on the Drug tier. Drugs are placed into tiers based on recommendations made by the P&T Committee. Tier 1 •  Most Generic Drugs or low-cost preferred Brand Drugs Tier 2 •   Non-preferred Generic Drugs • Preferred Brand Drugs •  Any other Drugs recommended by the P&T Committee based on drug safety, efficacy, and cost Tier 3 • Non0   Xxx-preferred xxxxxxxxx Brand Drugs • Drugs recommended by the P&T Committee based on drug safety, efficacy, and cost •  Drugs that generally have a preferred and often less costly therapeutic alternative at a lower tier Tier 4 •  Drugs that are biologics, and Drugs the FDA or drug manufacturer requires to be distributed through Network Specialty Pharmacies •  Drugs that require you to have special training or clinical monitoring •  Drugs that cost the plan more than $600 (net of rebates) for a one-month supply Visit xxxxxxxxxxxx.xxx/xxxxxxxx, use the Blue Shield mobile app, or contact Customer Service for more information on the Drug Formulary or to request a printed copy of the Formulary.

Prescription Drug Benefits. A. Coverage is available for Prescription Drugs if shown as covered in the Schedule of Benefits. The Prescription Drugs must be dispensed on or after the Member’s Effective Date by a licensed pharmacist or a pharmacy technician under the direction of a licensed pharmacist, upon the prescription of a Physician or an Allied Health Professional who is licensed to prescribe drugs. Benefits are available for outpatient prescription Drugs. Outpatient prescription based on the Allowable Charge that We determine and only those Prescription Drugs that We determine are self-administered Drugs approved by the U.S. Food and Drug Administration (FDA) for sale to the public through retail or mail-order pharmacies that are prescribed and are not provided for use on an inpatient basis. Drugs also include diabetic testing supplies. A Physician or Health Care Provider must prescribe all Drugs covered under this Benefit, including over-the-counter items. You must obtain all Drugs from a Participating Pharmacy, except as noted below. Drugs, items, and services that are not covered under this Benefit are listed in the Exclusions and limitations section. Some Drugs, most Specialty Drugs, and prescriptions for Drugs exceeding specific quantity limits require prior authorization to Medically Necess ary will be covered. The Certain Prescription Drugs may be subject to Step Therapy or require prior authorization process is described Authorization as shown in the Prior authorization/exception request/step therapy process section. You Schedule of Benefits. B. Prescription Drugs dispensed at retail or your Physician may request prior authorization from Blue Shield. Blue Shield’s through the mail are subject to the Prescription Drug Formulary is a list Copayment and any applicable Prescription Drug Deductible Amount shown in the Schedule of FDA-approved preferred Generic and Brand Drugs. This list helps Physicians or Health Care Providers prescribe Medically Necessary and cost-effective Drugs. Blue Shield’s Formulary is established and maintained by Blue Shield’s Pharmacy and Therapeutics (P&T) Committee. This committee consists of Physicians and pharmacists responsible for evaluating Drugs for relative safety, effectiveness, evidence-based health benefit, and comparative costBenefits. The committee also reviews new Drugs, dosage forms, usage, and clinical data Member may be required to update pay a different Copayment for the Formulary four times a year. Your Physician or Health Care Provider might prescribe a Drug even though it is not included in the Blue Shield Formulary. The Formulary is divided into Drug different drug tiers. The tiers Member may be required to pay a different Copayment depending on whether the Member’s Prescription Drugs are described in purchased at retail or through the chart belowmail. Your Copayment or Coinsurance will vary Prescription Drugs may be subject to quantity limitations. C. If a Prescription Drug Deductible Amount is applicable, this amount must be satisfied prior to any applicable Prescription Drug Copayment. The Prescription Drug Deductible Amount is separate from the Benefit Period Deductible Amount and does not accrue to the satisfaction of the Out-of-Pocket Amount. D. Prescription Drug Copayments are based on the Drug tierfollowing tier classifications shown in the Schedule of Benefits. Drugs are placed into tiers Tier placement is based on recommendations made by the P&T CommitteeOur evaluation of a particular medication’s clinical efficiency, safety, cost, and pharmacoeconomic factors. 1. Tier 1 • Most - A Prescription Drug that is a Generic Drugs or lowa low cost Brand-cost preferred Brand Drugs Name Drug. 2. Tier 2 • Non- A Prescription Drug that is a Brand-preferred Name Drug. 3. Tier 3 - A Prescription Drug that is a Brand-Name Drug or a Generic Drug that may have a therapeutic alternative as a Tier 1 or Tier 2 drug. Covered compounded drugs are included in this Tier. 4. Tier 4 - A Prescription Drug that is a Multi-Source Brand Drug. 5. Tier 5 - Injectable Prescription Drugs • Preferred Brand include those medications that are intended to be self-administered. However, insulin and injectable antihemophilic Prescription Drugs • Any other Drugs recommended may be included in another drug tier. E. Necessary insulin syringes and test strips are covered under the Prescription Drug Benefit. F. The Member can view Our Blue Selections Rx Member Guide on Our website at xxx.xxxxxx.xxx or request a copy by mail by calling Our pharmacy Benefit manager at the P&T Committee based telephone number indicated on drug the Member’s ID card. G. Our Drug Utilization Management Program features a set of closely aligned programs that are designed to promote Member safety, efficacyappropriate and cost effective use of medications, and cost Tier 3 • Non-preferred Brand Drugs • Drugs recommended by the P&T Committee based on drug safety, efficacy, and cost • Drugs that generally have a preferred and often less costly therapeutic alternative at a lower tier Tier 4 • Drugs that are biologics, and Drugs the FDA or drug manufacturer requires to be distributed through Network Specialty Pharmacies • Drugs that require you to have special training or clinical monitoring • Drugs that cost the plan more than $600 (net monitor health care quality. Examples of rebates) for a one-month supply Visit xxxxxxxxxxxx.xxx/xxxxxxxx, use the Blue Shield mobile app, or contact Customer Service for more information on the Drug Formulary or to request a printed copy of the Formulary.these programs include:

Prescription Drug Benefits. A. Coverage is available for Prescription Drugs if shown as covered in the Schedule of Benefits. The Prescription Drugs must be dispensed on or after the Member’s Effective Date by a licensed pharmacist or a pharmacy technician under the direction of a licensed pharmacist, upon the prescription of a Physician or an Allied Health Professional who is licensed to prescribe drugs. Benefits are available for outpatient prescription Drugs. Outpatient prescription based on the Allowable Charge that We determine and only those Prescription Drugs that We determine are self-administered Drugs approved by the U.S. Food and Drug Administration (FDA) for sale to the public through retail or mail-order pharmacies that are prescribed and are not provided for use on an inpatient basis. Drugs also include diabetic testing supplies. A Physician or Health Care Provider must prescribe all Drugs covered under this Benefit, including over-the-counter items. You must obtain all Drugs from a Participating Pharmacy, except as noted below. Drugs, items, and services that are not covered under this Benefit are listed in the Exclusions and limitations section. Some Drugs, most Specialty Drugs, and prescriptions for Drugs exceeding specific quantity limits require prior authorization to Medically Necessary will be covered. The Certain Prescription Drugs may be subject to Step Therapy or require prior authorization process is described Authorization as shown in the Prior authorization/exception request/step therapy process section. You Schedule of Benefits. B. Prescription Drugs dispensed at retail or your Physician may request prior authorization from Blue Shield. Blue Shield’s through the mail are subject to the Prescription Drug Formulary is a list Copayment and any applicable Prescription Drug Deductible Amount shown in the Schedule of FDA-approved preferred Generic and Brand Drugs. This list helps Physicians or Health Care Providers prescribe Medically Necessary and cost-effective Drugs. Blue Shield’s Formulary is established and maintained by Blue Shield’s Pharmacy and Therapeutics (P&T) Committee. This committee consists of Physicians and pharmacists responsible for evaluating Drugs for relative safety, effectiveness, evidence-based health benefit, and comparative costBenefits. The committee also reviews new Drugs, dosage forms, usage, and clinical data Member may be required to update pay a different Copayment for the Formulary four times a year. Your Physician or Health Care Provider might prescribe a Drug even though it is not included in the Blue Shield Formulary. The Formulary is divided into Drug different drug tiers. The tiers Member may be required to pay a different Copayment depending on whether the Member’s Prescription Drugs are described in purchased at retail or through the chart belowmail. Your Copayment or Coinsurance will vary Prescription Drugs may be subject to quantity limitations. C. If a Prescription Drug Deductible Amount is applicable, this amount must be satisfied prior to any applicable Prescription Drug Copayment. The Prescription Drug Deductible Amount is separate from the Benefit Period Deductible Amount and does not accrue to the satisfaction of the Out-of-Pocket Amount. D. Prescription Drug Copayments are based on the Drug tierfollowing tier classifications shown in the Schedule of Benefits. Drugs are placed into tiers Tier placement is based on recommendations made by the P&T CommitteeOur evaluation of a particular medication’s clinical efficiency, safety, cost, and pharmacoeconomic factors. 1. Tier 1 • Most - A Prescription Drug that is a Generic Drugs or lowa low cost Brand-cost preferred Brand Drugs Name Drug. 2. Tier 2 • Non- A Prescription Drug that is a Brand-preferred Name Drug. 3. Tier 3 - A Prescription Drug that is a Brand-Name Drug or a Generic Drug that may have a therapeutic alternative as a Tier 1 or Tier 2 drug. Covered compounded drugs are included in this Tier. 4. Tier 4 - A Prescription Drug that is a Multi-Source Brand Drug. 5. Tier 5 - Injectable Prescription Drugs • Preferred Brand include those medications that are intended to be self-administered. However, insulin and injectable antihemophilic Prescription Drugs • Any other Drugs recommended may be included in another drug tier. E. Necessary insulin syringes and test strips are covered under the Prescription Drug Benefit. F. The Member can view Our Blue Selections Rx Member Guide on Our website at xxx.xxxxxx.xxx or request a copy by mail by calling Our pharmacy Benefit manager at the P&T Committee based telephone number indicated on drug the Member’s ID card. G. Our Drug Utilization Management Program features a set of closely aligned programs that are designed to promote Member safety, efficacyappropriate and cost effective use of medications, and cost Tier 3 • Non-preferred Brand Drugs • Drugs recommended by the P&T Committee based on drug safety, efficacy, and cost • Drugs that generally have a preferred and often less costly therapeutic alternative at a lower tier Tier 4 • Drugs that are biologics, and Drugs the FDA or drug manufacturer requires to be distributed through Network Specialty Pharmacies • Drugs that require you to have special training or clinical monitoring • Drugs that cost the plan more than $600 (net monitor health care quality. Examples of rebates) for a one-month supply Visit xxxxxxxxxxxx.xxx/xxxxxxxx, use the Blue Shield mobile app, or contact Customer Service for more information on the Drug Formulary or to request a printed copy of the Formulary.these programs include: