Common use of Prescription Drug Services Note Clause in Contracts

Prescription Drug Services Note. Benefits for specialty drugs and injectable drugs that are not specialty drugs, excluding insulin, are as described in this section regardless of the place of service where the specialty drug or injectable drug that is not a specialty drug is dispensed or administered. Please see the Preventive Health Care Services section for coverage of prescription drugs, including certain insulin and other glucose lowering agents, on PIC’s Preventive Drug List. Drugs identified for our Split Fill Program may be provided in a 7 or 15 calendar day supply per prescription or refill even if prescribed for 31 calendar days. For a list of drugs on the Split Fill Program go to the member site on xxx.xxxxxxxxxxxx.xxx or call Customer Service. • Prescription drugs that can be self-administered for up to a 31- calendar day supply per prescription or refill. Tier 1 Generic: 80% of eligible charges after the deductible. Tier 2 Generic: 80% of eligible charges after the deductible. Preferred Brand: 80% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. • Mail order prescription drugs for up to a 31-calendar day supply per prescription or refill. Tier 1 Generic: 80% of eligible charges after the deductible. Tier 2 Generic: 80% of eligible charges after the deductible. Preferred Brand: 80% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. • Diabetic supplies, including over- the-counter diabetic supplies, including glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. 80% of eligible charges after the deductible. Not covered. • Injectable drugs up to a 31– calendar day supply per prescription or refill, except specialty drugs, women’s contraceptives, and insulin. NOTE: Injectable drugs, except insulin, will not be covered at the tier 1 generic, tier 2 generic, preferred brand or mail order benefit level. Tier 1 Generic: 50% of eligible charges after the deductible. Tier 2 Generic: 50% of eligible charges after the deductible. Preferred Brand: 50% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Specialty Drugs

Prescription Drug Services Note. Benefits for specialty drugs and injectable drugs that are not specialty drugs, excluding insulin, are as described in this section regardless of the place of service where the specialty drug or injectable drug that is not a specialty drug is dispensed or administered. Please see the Preventive Health Care Services section for coverage of prescription drugs, including certain insulin and other glucose lowering agents, on PIC’s Preventive Drug List. Drugs identified for our Split Fill Program may be provided in a 7 or 15 calendar day supply per prescription or refill even if prescribed for 31 calendar days. For a list of drugs on the Split Fill Program go to the member site on xxx.xxxxxxxxxxxx.xxx or call Customer Service. • Prescription drugs that can be self-administered for up to a 31- calendar day supply per prescription or refill. Tier 1 Generic: 80% of eligible charges after the deductible. Tier 2 Generic: 80% of eligible charges after the deductible. Preferred Brand: 80% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. • Mail order prescription drugs for up to a 31-calendar day supply per prescription or refill. Tier 1 Generic: 80% of eligible charges after the deductible. Tier 2 Generic: 80% of eligible charges after the deductible. Preferred Brand: 80% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. • Diabetic supplies, including over- the-counter diabetic supplies, including glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. 80% of eligible charges after the deductible. Not covered. • Injectable drugs up to a 31– calendar day supply per prescription or refill, except specialty drugs, women’s contraceptives, and insulin. NOTE: Injectable drugs, except insulin, will not be covered at the tier 1 generic, tier 2 generic, preferred brand or mail order benefit level. Tier 1 Generic: 50% of eligible charges after the deductible. Tier 2 Generic: 50% of eligible charges after the deductible. Preferred Brand: 50% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Specialty Drugs

Prescription Drug Services Note. Benefits for specialty drugs and injectable drugs that are not specialty drugs, excluding insulin, are as described in this section regardless of the place of service where the specialty drug or injectable drug that is not a specialty drug is dispensed or administered. Please see the Preventive Health Care Services section for coverage of prescription drugs, including certain insulin and other glucose lowering agents, on PIC’s Preventive Drug List. Drugs identified for our Split Fill Program may be provided in a 7 or 15 calendar day supply per prescription or refill even if prescribed for 31 calendar days. For a list of drugs on the Split Fill Program go to the member site on xxx.xxxxxxxxxxxx.xxx or call Customer Service. • Prescription drugs that can be self-administered for up to a 31- calendar day supply per prescription or refill. Tier 1 Generic: 80% of eligible charges after the deductible. Tier 2 Generic: 80100% of eligible charges after the deductible. Preferred Brand: 80100% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. • Mail order prescription drugs for up to a 31-calendar day supply per prescription or refill. Tier 1 Generic: 80% of eligible charges after the deductible. Tier 2 Generic: 80100% of eligible charges after the deductible. Preferred Brand: 80100% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. • Diabetic supplies, including over- the-counter diabetic supplies, including glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. 80100% of eligible charges after the deductible. Not covered. • Injectable drugs up to a 31– calendar day supply per prescription or refill, except specialty drugs, women’s contraceptives, and insulin. NOTE: Injectable drugs, except insulin, will not be covered at the tier 1 generic, tier 2 generic, preferred brand or mail order benefit level. Tier 1 Generic: 50% of eligible charges after the deductible. Tier 2 Generic: 50100% of eligible charges after the deductible. Preferred Brand: 50100% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Specialty Drugs

Prescription Drug Services Note. Benefits for specialty drugs and injectable drugs that are not specialty drugs, excluding insulin, are as described in this section regardless of the place of service where the specialty drug or injectable drug that is not a specialty drug is dispensed or administered. Please see the Preventive Health Care Services section for coverage of prescription drugs, including certain insulin and other glucose lowering agents, on PIC’s Preventive Drug List. Drugs identified for our Split Fill Program may be provided in a 7 or 15 calendar day supply per prescription or refill even if prescribed for 31 calendar days. The copayment (if applicable) will be prorated. For a list of drugs on the Split Fill Program go to the member site on xxx.xxxxxxxxxxxx.xxx or call Customer Service. • Prescription drugs that can be self-administered for up to a 31- calendar day supply per prescription or refill. Tier 1 Generic: 80100% of eligible charges after the deductiblea $25 member copayment per prescription or refill. Deductible does not apply. Tier 2 Generic: 80100% of eligible charges after the deductiblea $25 member copayment per prescription or refill. Deductible does not apply. Preferred Brand: 8070% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. • Mail order prescription drugs for up to a 31-calendar day supply per prescription or refill. Tier 1 Generic: 80100% of eligible charges after the deductiblea $25 member copayment per prescription or refill. Deductible does not apply. Tier 2 Generic: 80100% of eligible charges after the deductiblea $25 member copayment per prescription or refill. Deductible does not apply. Preferred Brand: 8070% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. • Diabetic supplies, including over- the-counter diabetic supplies, including glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. 8070% of eligible charges after the deductible. Not covered. • Injectable drugs up to a 31– calendar day supply per prescription or refill, except specialty drugs, women’s contraceptives, and insulin. NOTE: Injectable drugs, except insulin, will not be covered at the tier 1 generic, tier 2 generic, preferred brand or mail order benefit level. Tier 1 Generic: 50% of eligible charges after the deductible. Tier 2 Generic: 50% of eligible charges after the deductible. Preferred Brand: 50% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Specialty Drugs.

Prescription Drug Services Note. Benefits for specialty drugs and injectable drugs that are not specialty drugs, excluding insulin, are as described in this section regardless of the place of service where the specialty drug or injectable drug that is not a specialty drug is dispensed or administered. Please see the Preventive Health Care Services section for coverage of prescription drugs, including certain insulin and other glucose lowering agents, on PIC’s Preventive Drug List. Drugs identified for our Split Fill Program may be provided in a 7 or 15 calendar day supply per prescription or refill even if prescribed for 31 calendar days. The copayment (if applicable) will be prorated. For a list of drugs on the Split Fill Program go to the member site on xxx.xxxxxxxxxxxx.xxx or call Customer Service. • Prescription drugs that can be self-administered for up to a 31- calendar day supply per prescription or refill. Tier 1 Generic: 80100% of eligible charges after the deductiblea $25 member copayment per prescription or refill. Tier 2 Generic: 80% of eligible charges after the deductibleDeductible does not apply. Preferred Brand: 8070% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. • Mail order prescription drugs for up to a 31-calendar day supply per prescription or refill. Tier 1 Generic: 80100% of eligible charges after the deductiblea $25 member copayment per prescription or refill. Tier 2 Generic: 80% of eligible charges after the deductibleDeductible does not apply. Preferred Brand: 8070% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. • Diabetic supplies, including over- the-counter diabetic supplies, including glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. 8070% of eligible charges after the deductible. Not covered. • Injectable drugs up to a 31– calendar day supply per prescription or refill, except specialty drugs, women’s contraceptives, and insulin. NOTE: Injectable drugs, except insulin, will not be covered at the tier 1 generic, tier 2 generic, preferred brand or mail order benefit level. Tier 1 Generic: 50% of eligible charges after the deductible. Tier 2 Generic: 50% of eligible charges after the deductible. Preferred Brand: 50% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Specialty Drugs.