Common use of Preventive Contraceptive Methods and Counseling for Women Clause in Contracts

Preventive Contraceptive Methods and Counseling for Women. PIC covers preventive contraceptive methods and counseling services received during the calendar year by female members as described in the Preventive Health Care Services Schedule (“Schedule”) and according to the frequency and time frames stated in the Schedule. The Schedule, which includes the preventive contraceptive methods and counseling services for women provided by the Affordable Care Act, is available on PIC’s member website or by calling PIC Customer Service. This coverage includes the full range of Food and Drug Administration approved contraceptive methods for women with reproductive capacity, including women’s contraceptive drugs, devices, and delivery methods obtained from a retail pharmacy, a mail order pharmacy, or received at a provider’s office. Self-administered hormonal contraceptives may be prescribed by a physician, physician assistant, advanced practice registered nurse or a licensed pharmacist. Women’s prescription contraceptives received at a retail pharmacy or mail order pharmacy: • Generic oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. Preferred Brand: 100% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Women’s prescription contraceptives, sterilization procedures, and member education received at a provider’s office: • Generic injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. 100% of eligible charges after the deductible. Not covered. • Sterilization procedures, excluding the reversal of sterilization procedures. 100% of eligible charges. Deductible does not apply. Not covered. • Member education and counseling about contraceptive methods. 100% of eligible charges. Deductible does not apply. Same as the participating provider benefit. Your provider may request an exception for coverage with no cost sharing for a brand name drug for which a generic drug is available. Your provider or you may contact PIC Customer Service for a copy of the written guidelines and procedures or for assistance in requesting an exception. If the exception is approved, PIC will pay 100% of the eligible charges for the brand name preventive contraceptive drug when you obtain it from a participating provider, and the deductible will not apply. An exception is valid for the duration of the prescription while you are covered under this contract, including refills. Your provider may request an exception for subsequent prescriptions following the procedure described in the Prescription Drug Services section. The exception does not apply if PIC removes the drug from the formulary for safety reasons. A previously granted exception ends when XXX removes the drug from the formulary for safety reasons.

Preventive Contraceptive Methods and Counseling for Women. PIC covers preventive contraceptive methods and counseling services received during the calendar year by female members as described in the Preventive Health Care Services Schedule (“Schedule”) and according to the frequency and time frames stated in the Schedule. The Schedule, which includes the preventive contraceptive methods and counseling services for women provided by the Affordable Care Act, is available on PIC’s member website or by calling PIC Customer Service. This coverage includes the full range of Food and Drug Administration approved contraceptive methods for women with reproductive capacity, including women’s contraceptive drugs, devices, and delivery methods obtained from a retail pharmacy, a mail order pharmacy, or received at a provider’s office. Self-administered hormonal contraceptives may be prescribed by a physician, physician assistant, advanced practice registered nurse or a licensed pharmacist. Women’s prescription contraceptives received at a retail pharmacy or mail order pharmacy: • Generic oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. Preferred Brand: 10080% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Women’s prescription contraceptives, sterilization procedures, and member education received at a provider’s office: • Generic injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. 10080% of eligible charges after the deductible. Not covered. • Sterilization procedures, excluding the reversal of sterilization procedures. 100% of eligible charges. Deductible does not apply. Not covered. • Member education and counseling about contraceptive methods. 100% of eligible charges. Deductible does not apply. Same as the participating provider benefit. Your provider may request an exception for coverage with no cost sharing for a brand name drug for which a generic drug is available. Your provider or you may contact PIC Customer Service for a copy of the written guidelines and procedures or for assistance in requesting an exception. If the exception is approved, PIC will pay 100% of the eligible charges for the brand name preventive contraceptive drug when you obtain it from a participating provider, and the deductible will not apply. An exception is valid for the duration of the prescription while you are covered under this contract, including refills. Your provider may request an exception for subsequent prescriptions following the procedure described in the Prescription Drug Services section. The exception does not apply if PIC removes the drug from the formulary for safety reasons. A previously granted exception ends when XXX removes the drug from the formulary for safety reasons.

Preventive Contraceptive Methods and Counseling for Women. PIC covers preventive contraceptive methods and counseling services received during the calendar year by female members as described in the Preventive Health Care Services Schedule (“Schedule”) and according to the frequency and time frames stated in the Schedule. The Schedule, which includes the preventive contraceptive methods and counseling services for women provided by the Affordable Care Act, is available on PIC’s member website or by calling PIC Customer Service. This coverage includes the full range of Food and Drug Administration approved contraceptive methods for women with reproductive capacity, including women’s contraceptive drugs, devices, and delivery methods obtained from a retail pharmacy, a mail order pharmacy, or received at a provider’s office. Self-administered hormonal contraceptives may be prescribed by a physician, physician assistant, advanced practice registered nurse or a licensed pharmacist. Women’s prescription contraceptives received at a retail pharmacy or mail order pharmacy: • Generic oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. Preferred Brand: 10060% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Women’s prescription contraceptives, sterilization procedures, and member education received at a provider’s office: • Generic injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. 10080% of eligible charges after the deductible. Not covered. • Sterilization procedures, excluding the reversal of sterilization procedures. 100% of eligible charges. Deductible does not apply. Not covered. • Member education and counseling about contraceptive methods. 100% of eligible charges. Deductible does not apply. Same as the participating provider benefit. Your provider may request an exception for coverage with no cost sharing for a brand name drug for which a generic drug is available. Your provider or you may contact PIC Customer Service for a copy of the written guidelines and procedures or for assistance in requesting an exception. If the exception is approved, PIC will pay 100% of the eligible charges for the brand name preventive contraceptive drug when you obtain it from a participating provider, and the deductible will not apply. An exception is valid for the duration of the prescription while you are covered under this contract, including refills. Your provider may request an exception for subsequent prescriptions following the procedure described in the Prescription Drug Services section. The exception does not apply if PIC removes the drug from the formulary for safety reasons. A previously granted exception ends when XXX removes the drug from the formulary for safety reasons.

Preventive Contraceptive Methods and Counseling for Women. PIC covers preventive contraceptive methods and counseling services received during the calendar year by female members as described in the Preventive Health Care Services Schedule (“Schedule”) and according to the frequency and time frames stated in the Schedule. The Schedule, which includes the preventive contraceptive methods and counseling services for women provided by the Affordable Care Act, is available on PIC’s member website or by calling PIC Customer Service. This coverage includes the full range of Food and Drug Administration approved contraceptive methods for women with reproductive capacity, including women’s contraceptive drugs, devices, and delivery methods obtained from a retail pharmacy, a mail order pharmacy, or received at a provider’s office. Self-administered hormonal contraceptives may be prescribed by a physician, physician assistant, advanced practice registered nurse or a licensed pharmacist. Women’s prescription contraceptives received at a retail pharmacy or mail order pharmacy: • Generic oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. Preferred Brand: 10070% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Women’s prescription contraceptives, sterilization procedures, and member education received at a provider’s office: • Generic injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. 10070% of eligible charges after the deductible. Not covered. • Sterilization procedures, excluding the reversal of sterilization procedures. 100% of eligible charges. Deductible does not apply. Not covered. • Member education and counseling about contraceptive methods. 100% of eligible charges. Deductible does not apply. Same as the participating provider benefit. Your provider may request an exception for coverage with no cost sharing for a brand name drug for which a generic drug is available. Your provider or you may contact PIC Customer Service for a copy of the written guidelines and procedures or for assistance in requesting an exception. If the exception is approved, PIC will pay 100% of the eligible charges for the brand name preventive contraceptive drug when you obtain it from a participating provider, and the deductible will not apply. An exception is valid for the duration of the prescription while you are covered under this contract, including refills. Your provider may request an exception for subsequent prescriptions following the procedure described in the Prescription Drug Services section. The exception does not apply if PIC removes the drug from the formulary for safety reasons. A previously granted exception ends when XXX removes the drug from the formulary for safety reasons.

Preventive Contraceptive Methods and Counseling for Women. PIC covers preventive contraceptive methods and counseling services received during the calendar year by female members as described in the Preventive Health Care Services Schedule (“Schedule”) and according to the frequency and time frames stated in the Schedule. The Schedule, which includes the preventive contraceptive methods and counseling services for women provided by the Affordable Care Act, is available on PIC’s member website or by calling PIC Customer Service. This coverage includes the full range of Food and Drug Administration approved contraceptive methods for women with reproductive capacity, including women’s contraceptive drugs, devices, and delivery methods obtained from a retail pharmacy, a mail order pharmacy, or received at a provider’s office. Self-administered hormonal contraceptives may be prescribed by a physician, physician assistant, advanced practice registered nurse or a licensed pharmacist. Women’s prescription contraceptives received at a retail pharmacy or mail order pharmacy: • Generic oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. Preferred Brand: 10080% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Women’s prescription contraceptives, sterilization procedures, and member education received at a provider’s office: • Generic injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. 10080% of eligible charges after the deductible. Not covered. • Sterilization procedures, excluding the reversal of sterilization procedures. 100% of eligible charges. Deductible does not apply. Not covered. • Member education and counseling about contraceptive methods. 100% of eligible charges. Deductible does not apply. Same as the participating provider benefit. Your provider may request an exception for coverage with no cost sharing for a brand name drug for which a generic drug is available. Your provider or you may contact PIC Customer Service for a copy of the written guidelines and procedures or for assistance in requesting an exception. If the exception is approved, PIC will pay 100% of the eligible charges for the brand name preventive contraceptive drug when you obtain it from a participating provider, and the deductible will not apply. An exception is valid for the duration of the prescription while you are covered under this contract, including refills. Your provider may request an exception for subsequent prescriptions following the procedure described in the Prescription Drug Services section. The exception does not apply if PIC removes the drug from the formulary for safety reasons. A previously granted exception ends when XXX removes the drug from the formulary for safety reasons.

Preventive Contraceptive Methods and Counseling for Women. PIC covers preventive contraceptive methods and counseling services received during the calendar year by female members as described in the Preventive Health Care Services Schedule (“Schedule”) and according to the frequency and time frames stated in the Schedule. The Schedule, which includes the preventive contraceptive methods and counseling services for women provided by the Affordable Care Act, is available on PIC’s member website or by calling PIC Customer Service. This coverage includes the full range of Food and Drug Administration approved contraceptive methods for women with reproductive capacity, including women’s contraceptive drugs, devices, and delivery methods obtained from a retail pharmacy, a mail order pharmacy, or received at a provider’s office. Self-administered hormonal contraceptives may be prescribed by a physician, physician assistant, advanced practice registered nurse or a licensed pharmacist. Women’s prescription contraceptives received at a retail pharmacy or mail order pharmacy: • Generic oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. Preferred Brand: 10070% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Women’s prescription contraceptives, sterilization procedures, and member education received at a provider’s office: • Generic injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. 10070% of eligible charges after the deductible. Not covered. • Sterilization procedures, excluding the reversal of sterilization procedures. 100% of eligible charges. Deductible does not apply. Not covered. • Member education and counseling about contraceptive methods. 100% of eligible charges. Deductible does not apply. Same as the participating provider benefit. Your provider may request an exception for coverage with no cost sharing for a brand name drug for which a generic drug is available. Your provider or you may contact PIC Customer Service for a copy of the written guidelines and procedures or for assistance in requesting an exception. If the exception is approved, PIC will pay 100% of the eligible charges for the brand name preventive contraceptive drug when you obtain it from a participating provider, and the deductible will not apply. An exception is valid for the duration of the prescription while you are covered under this contract, including refills. Your provider may request an exception for subsequent prescriptions following the procedure described in the Prescription Drug Services section. The exception does not apply if PIC removes the drug from the formulary for safety reasons. A previously granted exception ends when XXX removes the drug from the formulary for safety reasons.

Preventive Contraceptive Methods and Counseling for Women. PIC covers preventive contraceptive methods and counseling services received during the calendar year by female members as described in the Preventive Health Care Services Schedule (“Schedule”) and according to the frequency and time frames stated in the Schedule. The Schedule, which includes the preventive contraceptive methods and counseling services for women provided by the Affordable Care Act, is available on PIC’s member website or by calling PIC Customer Service. This coverage includes the full range of Food and Drug Administration approved contraceptive methods for women with reproductive capacity, including women’s contraceptive drugs, devices, and delivery methods obtained from a retail pharmacy, a mail order pharmacy, or received at a provider’s office. Self-administered hormonal contraceptives may be prescribed by a physician, physician assistant, advanced practice registered nurse or a licensed pharmacist. Women’s prescription contraceptives received at a retail pharmacy or mail order pharmacy: • Generic oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name oral, injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. Preferred Brand: 10075% of eligible charges after the deductible. Non-Preferred Brand and Non-formulary: Not covered. Not covered. Women’s prescription contraceptives, sterilization procedures, and member education received at a provider’s office: • Generic injectable, implantable, and insertable contraceptives that require a prescription under applicable law; and • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which no generic alternative exists. 100% of eligible charges. Deductible does not apply. Not covered. • Brand name injectable, implantable, and insertable contraceptives that require a prescription under applicable law, and for which a generic alternative exists. 10075% of eligible charges after the deductible. Not covered. • Sterilization procedures, excluding the reversal of sterilization procedures. 100% of eligible charges. Deductible does not apply. Not covered. • Member education and counseling about contraceptive methods. 100% of eligible charges. Deductible does not apply. Same as the participating provider benefit. Your provider may request an exception for coverage with no cost sharing for a brand name drug for which a generic drug is available. Your provider or you may contact PIC Customer Service for a copy of the written guidelines and procedures or for assistance in requesting an exception. If the exception is approved, PIC will pay 100% of the eligible charges for the brand name preventive contraceptive drug when you obtain it from a participating provider, and the deductible will not apply. An exception is valid for the duration of the prescription while you are covered under this contract, including refills. Your provider may request an exception for subsequent prescriptions following the procedure described in the Prescription Drug Services section. The exception does not apply if PIC removes the drug from the formulary for safety reasons. A previously granted exception ends when XXX removes the drug from the formulary for safety reasons.