Common use of Preventive Care Clause in Contracts

Preventive Care. Prescription and over-the-counter drugs which have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) (to be implemented in the quantities and within the time period allowed under applicable law) or as required by state law will be covered and will not be subject to any Copayment or dollar maximums. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so You are encouraged to contact them in advance. Formulas for the Treatment of Phenylketonuria or Other Heritable Diseases. Dietary formulas necessary for the treatment of phenylketonuria or other heritable diseases are covered to the same extent as any other Covered Drug available only on the orders of a Health Care Practitioner. Amino Acid-Based Elemental Formulas. Formulas, regardless of the formula delivery method, used for the diagnosis and treatment of: • immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins; • severe food protein-induced enterocolitis syndromes; • eosinophilic disorders, as evidenced by the results of biopsy; and • disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from Your Health Care Practitioner is required. Orally Administered Anticancer Medication. Benefits are available for Medically Necessary orally administered anticancer medication that is used to kill or slow the growth of cancerous cells. Copayments will not apply to certain orally administered anticancer medications. To determine if a specific drug is included in this benefit, contact customer service at the toll-free number on Your identification card. Specialty Drugs. Benefits are available for Specialty Drugs as described in Specialty Pharmacy Program. Selecting a Pharmacy When You need a Prescription Order filled, You should use a Participating Pharmacy. Each prescription or refill is subject to the Copayment shown in the Schedule of Copayments and Benefit Limits and any applicable pricing differences. You may be required to pay for limited or non-Covered Services. No claim forms are required. Although You can go to any Participating Pharmacy, Your benefits for drugs and other items covered under this provision will be greater when You obtain them from a Preferred Participating Pharmacy. Your Copayment will be less when using a Preferred Participating Pharmacy. If You are unsure whether a Pharmacy is a Participating Pharmacy, You may access the website at xxxxx://xxx.xxxxxx.xxx/onlinedirectory/important_info_rx.htm. Preferred Participating Pharmacies will also be identified. You can also call customer service at the toll-free telephone number on the back of Your identification card for information regarding Participating Pharmacies and Preferred Participating Pharmacies.

Preventive Care. Prescription and over-the-counter drugs which have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) (to be implemented in the quantities and within the time period allowed under applicable law) or as required by state law will be covered and will not be subject to any Copayment or dollar maximums. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so You are encouraged to contact them in advance. Formulas for the Treatment of Phenylketonuria or Other Heritable Diseases. Dietary formulas necessary for the treatment of phenylketonuria or other heritable diseases are covered to the same extent as any other Covered Drug available only on the orders of a Health Care Practitioner. Amino Acid-Based Elemental Formulas. Formulas, regardless of the formula delivery method, used for the diagnosis and treatment of: • immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins; • severe food protein-induced enterocolitis syndromes; • eosinophilic disorders, as evidenced by the results of biopsy; and • disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from Your Health Care Practitioner is required. Orally Administered Anticancer Medication. Benefits are available for Medically Necessary orally administered anticancer medication that is used to kill or slow the growth of cancerous cells. Copayments will not apply to certain orally administered anticancer medications. To determine if a specific drug is included in this benefit, contact customer service at the toll-free number on Your identification card. Specialty Drugs. Benefits are available for Specialty Drugs as described in Specialty Pharmacy Program. Selecting a Pharmacy When You need a Prescription Order filled, You should use a Participating Pharmacy. Each prescription or refill is subject to the Copayment shown in the Schedule of Copayments and Benefit Limits SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS and any applicable pricing differences. You may be required to pay for limited or non-Covered Services. No claim forms are required. Although You can go to any Participating Pharmacy, Your benefits for drugs and other items covered under this provision will be greater when You obtain them from a Preferred Participating Pharmacy. Your Copayment will be less when using a Preferred Participating Pharmacy. If You are unsure whether a Pharmacy is a Participating Pharmacy, You may access the website at xxxxx://xxx.xxxxxx.xxx/onlinedirectory/important_info_rx.htmxxx.xxxxxx.xxx/xxxxxxxxxxxxxxx/xxxxxxxxx_xxxx_xx.xxx. Preferred Participating Pharmacies will also be identified. You can also call customer service at the toll-free telephone number on the back of Your identification card for information regarding Participating Pharmacies and Preferred Participating Pharmacies.

Preventive Care. Prescription and over-the-counter drugs which have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) (to be implemented in the quantities and within the time period allowed under applicable law) or as required by state law will be covered and will not be subject to any Copayment or dollar maximums. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so You are encouraged to contact them in advance. Formulas for the Treatment of Phenylketonuria or Other Heritable Diseases. Dietary formulas necessary for the treatment of phenylketonuria or other heritable diseases are covered to the same extent as any other Covered Drug available only on the orders of a Health Care Practitioner. Amino Acid-Based Elemental Formulas. Formulas, regardless of the formula delivery method, used for the diagnosis and treatment of: • immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins; • severe food protein-induced enterocolitis syndromes; • eosinophilic disorders, as evidenced by the results of biopsy; and • disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from Your Health Care Practitioner is required. Orally Administered Anticancer Medication. Benefits are available for Medically Necessary orally administered anticancer medication that is used to kill or slow the growth of cancerous cells. Copayments will not apply to certain orally administered anticancer medications. To determine if a specific drug is included in this benefit, contact customer service at the toll-free number on Your identification card. Specialty Drugs. Benefits are available for Specialty Drugs as described in Specialty Pharmacy Program. Selecting a Pharmacy When You need a Prescription Order filled, You should use a Participating Pharmacy. Each prescription or refill is subject to the Copayment shown in the Schedule of Copayments and Benefit Limits and any applicable pricing differences. You may be required to pay for limited or non-Covered Services. No claim forms are required. Although You can go to any Participating Pharmacy, Your benefits for drugs and other items covered under this provision will be greater when You obtain them from a Preferred Participating Pharmacy. Your Copayment will be less when using a Preferred Participating Pharmacy. If You are unsure whether a Pharmacy is a Participating Pharmacy, You may access the website at xxxxx://xxx.xxxxxx.xxx/onlinedirectory/important_info_rx.htmxxx.xxxxxx.xxx/xxxxxxxxxxxxxxx/xxxxxxxxx_xxxx_xx.xxx. Preferred Participating Pharmacies will also be identified. You can also call customer service at the toll-free telephone number on the back of Your identification card for information regarding Participating Pharmacies and Preferred Participating Pharmacies.

Preventive Care. Prescription and over-the-counter drugs which have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) (to be implemented in the quantities and within the time period allowed under applicable law) or as required by state law will be covered and will not be subject to any Copayment or dollar maximums. Select Vaccinations obtained through certain Participating Pharmacies. Benefits for select vaccinations are shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. These vaccinations are available through certain Participating Pharmacies that have contracted with HMO to provide this service. To locate one of these Participating Pharmacies in the Pharmacy Vaccine Network in Your area and to determine which vaccinations are covered under this benefit, access the website at xxx.xxxxxx.xxx or contact customer service at the toll-free number on Your identification card. Each Participating Pharmacy included in the Pharmacy Vaccine Network that has contracted with HMO to provide this service may have age, scheduling, or other requirements that will apply, so You you are encouraged to contact them in advance. Formulas for the Treatment of Phenylketonuria or Other Heritable Diseases. Dietary formulas necessary for the treatment of phenylketonuria or other heritable diseases are covered to the same extent as any other Covered Drug available only on the orders of a Health Care Practitioner. Amino Acid-Based Elemental Formulas. Formulas, regardless of the formula delivery method, used for the diagnosis and treatment of: • immunoglobulin Immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins; • severe Severe food protein-induced enterocolitis syndromes; • eosinophilic Eosinophilic disorders, as evidenced by the results of biopsy; and • disorders Disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract. A Prescription Order from Your Health Care Practitioner is required. Orally Administered Anticancer Medication. Benefits are available for Medically Necessary orally administered anticancer medication that is used to kill or slow the growth of cancerous cells. Copayments will not apply to certain orally administered anticancer medications. To determine if a specific drug is included in this benefit, contact customer service at the toll-free number on Your identification card. Specialty Drugs. Benefits are available for Specialty Drugs as described in Specialty Pharmacy Program. Selecting a Pharmacy When You need a Prescription Order filled, You should use a Participating Pharmacy. Each prescription or refill is subject to the Copayment shown in the Schedule of Copayments and Benefit Limits and any applicable pricing differences. You may be required to pay for limited or non-Covered Services. No claim forms are required. Although You can go to any Participating Pharmacy, Your benefits for drugs and other items covered under this provision will be greater when You obtain them from a Preferred Participating Pharmacy. Your Copayment will be less when using a Preferred Participating Pharmacy. If You are unsure whether a Pharmacy is a Participating Pharmacy, You may access the website at xxxxx://xxx.xxxxxx.xxx/onlinedirectory/important_info_rx.htm. Preferred Participating Pharmacies will also be identified. You can also call customer service at the toll-free telephone number on the back of Your identification card for information regarding Participating Pharmacies and Preferred Participating Pharmacies.