Common use of Preventive Drugs Clause in Contracts

Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $7 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $25 Not Covered Tier 3: $40 Not Covered Tier 4: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered by a Provider (other than a Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Benefits.

Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $7 10 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $25 35 Not Covered Tier 3: $40 60 Not Covered Tier 4: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered by a Provider (other than a Covered Benefits Network Pharmacy Non-network Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Benefits.

Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. When a generic brand (Tier 1 Preventive1) is not available, a preferred brand (Tier 2) will be covered at the Tier level. Tier 1: $0 Tier 1 Non-preventive: $7 Not Covered Tier 2 Preventive2: $0 Tier 2 Non-preventive: $25 30 Not Covered Tier 3: $40 50 Not Covered Tier 4: $75 Not Covered Tier 5: NRT and Smoking Cessation drugs are only placed place in Tier 1, Tier 2, Tier 3, or Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered by a Provider (other than a Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Medic Benefits.

Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $7 10 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $25 40 Not Covered Tier 3: $40 80 Not Covered Tier 4: $150 Not Covered Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 34. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered by a Provider (other than a Covered Benefits Network Pharmacy Non-network Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Benefits.

Preventive Drugs. When purchased at any pharmacy: Must be Mustbe prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription SPereescription Drug section for details. When a generic brand (Tier 1 Preventive1) is not available, a preferred brand (Tier 2) will be covered at the Tier level. Tier 1: $0 Tier 1 Non-preventive: $7 Not Covered Tier 2 Preventive2: $0 Tier 2 Non-preventive: $25 35 Not Covered Tier 3: $40 70 Not Covered Tier 44 and Tier 5: NRT and NRaTnd Smoking Cessation drugs are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered by a Provider (other than a Pharmacy). See the Summary of Medical Medic Benefits. See the Summary of Medical Medic Benefits.

Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $7 15 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $25 50 Not Covered Tier 3: $40 100 Not Covered Tier 4: $200 Not Covered Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 34. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered by a Provider (other than a Covered Benefits Network Pharmacy Non-network Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Benefits.

Preventive Drugs. When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $7 10 Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $25 35 Not Covered Tier 3: $40 70 Not Covered Tier 44 and Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, or Tier 3. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered Prescription Drugs Administered by a Provider (other than a Covered Benefits Network Pharmacy Non-network Pharmacy). See the Summary of Medical Benefits. See the Summary of Medical Benefits.